Clinical Note Document - Local Development build (v26.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
The Clinical Note Document provides a consistent method for passing clinical information relevant to and from one healthcare organisation to another safely and securely using existing point-to-point transfer mechanisms. This Implementation Guide includes scenarios for when the Clinical Note Document could be applied and recommends a structured format based on FHIR artefacts. At this stage, the guide does not explain how the document should be exchanged. Instead, it assumes that organisations will continue using their current point-to-point transfer mechanisms.
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Official URL: http://digitalhealth.gov.au/fhir/cnd/ImplementationGuide/au.gov.digitalhealth.cnd
This guide is a collection of HL7® FHIR® Release 4 (R4) artefacts authored and maintained by the Australian Digital Health Agency.
The goal of the Clinical Note Document is to provide a consistent method for passing clinical information relevant to a clinical care setting from one healthcare organisation to another in a safe and secure manner using existing point-to-point transfer mechanisms. It aims at addressing an identified gap in how healthcare organisations transfer health information between clinical information systems (CIS) where a standard format does not exist.
This Implementation Guide outlines scenarios where the Clinical Note Document is beneficial and recommends a structured format using FHIR artefacts. At this stage, it doesn't provide any guidance on how the Clinical Note Document may be exchanged. It assumes that already established exchange mechanisms will continue to be used in the first instance.
The Clinical Note Document FHIR Implementation Guide is an open specification, allowing implementers to extend it for their own use cases as long as they meet its conformance requirements.
Overview
The development of the Clinical Note Document has emerged from the aged care clinical information systems requirements workstream (ACCIS), which responded to recommendations 68 and 109 of the Royal Commission into Quality and Safety.
The development of the ACCIS requirements identified a gap in how healthcare organisations transfer clinical information to and from a clinical information system (CIS) to another clinical software system where a standard format does not already exist.
The development of the Clinical Note Document supports and aligns with interoperability as a strategic priority in the Australian National Digital Health Strategy, as outlined in the National Healthcare Interoperability Plan 2023-2028, which states that interoperability of clinical information is essential to high-quality, sustainable health care in which clinical information is collected in a prescribed manner and can be shared in real time with patients and their providers.
Specifically, Action 3.5 in Priority Area 3 – Information Sharing is to assess the current interoperability between GP and residential care and primary care systems, identifying issues, requirements and potential solutions to resolve issues.
The Clinical Note Document also aligns with Outcome 3 of the Aged Care Data and Digital Strategy 2024-2029: Data is shared and reused securely to deliver a sustainable and continually improving care delivery system. Best efforts were made to align the Clinical Note Document to the National Minimum Data Set v1.
Standards create consistency and compatibility, support a single source of truth, and enable interoperability. This document describes the scenarios and business requirements for the Clinical Note Document, leveraging existing standards and infrastructure.
Efforts to standardise software systems aligns to the interoperability principles stated in the National Healthcare Interoperability Plan (Agency2023). The sections in this document specifically aligns to the following interoperability principles:
health information is discoverable and accessible
national healthcare identifiers are used across the healthcare sector
national digital health standards and specifications are agreed and adopted
core national healthcare digital infrastructure is used across the sector
collaboration and stakeholder engagement underpin interoperability.
The standardising of software systems needs to reflect the above interoperability principles.
How to read this guide
This guide is divided into several pages which are listed at the top of each page in the menu bar.
Home: This page provides the introduction and scope for the Implementation Guide.
Conformance: This page describes the set of rules to claim conformance to this guide including the expectations for Mandatory and Must Support elements.
Guidance: These pages provide additional guidance on some topics to ensure a clearer pathway for consistent implementation by adopting organisations. These topics are:
Terminology: This page provide guidance on some key terminology concepts that are key for interoperability.
Author and Recipient: This page provides guidance on how to represent authoring and receiving parties of the Clinical Note Document.
Use Cases: This page highlights some potential use cases for the Clinical Note Document.
Security and Privacy: This page provides Security requirements including TLS encryption standards, FHIR communications security, and privacy obligations for Clinical Note Document implementations.
FHIR Artefacts: These pages provide detailed descriptions and formal definitions for all the FHIR artefacts defined in this guide.
Profiles and Extensions: This page lists the FHIR profiles and extensions that are defined in this guide.
Terminology Artefacts: This page lists the FHIR terminology that are defined in this guide.
Examples: This page lists all the examples used in this Implementation Guide.
Support: This section provides support resources for implementers.
Known Issues: This page lists known issues with this specification at the time of publishing along with their descriptions.
Downloads: This page provides links to downloadable artefacts including the Agency FHIR NPM package.
Change Log: This page documents the version history and changes made to this implementation guide across different releases.
Licence and Legal: This page lists the licensing, copyright, and disclaimers under which this guide is issued.
Document purpose and scope
The primary aim of this implementation guide is to support implementers adopting the Clinical Note Document (CND) using FHIR, Release 4 (v4.0.1) [HL7FHIR4]. It provides the technical specifications, FHIR profiles, extensions, and terminology definitions required to create and consume interoperable Clinical Note Documents across healthcare organisations.
This document describes specific conformance expectations such as profile obligations, cardinality and terminology constraints, validation requirements, and implementation guidance needed for consistent CND exchange. Other requirements, such as local workflow design, user interface behaviour, and organisation-specific operational processes, are managed separately and remain the responsibility of implementing systems.
Reference has been made to International and Australian Standards, and to Standards from HL7. The following standards are referred to in the text in such a way that some or all of its content constitutes requirements for the purposes of this specification:
Wherever possible, material in this specification is based on existing standards. All efforts have been made to minimise divergence from the HL7 Australia standards (AU Core [HL7AUCIG] and AU Base [HL7AUBIG]) to provide for system interoperability and compatibility with other profiles. Issues of an editorial nature in the source material (such as spelling or punctuation errors) are intentionally reproduced.
Intended audience
This implementation guide is aimed at software development teams, architects, and designers that implement the Clinical Note Document.
This implementation guide and related artefacts are technical in nature and the audience is expected to be familiar with the language of health data specifications and to have some familiarity with health information standards and specifications, such as FHIR.
Relationships with other work
This implementation guide builds on other specifications, helping ensure a consistent approach to data sharing that should ease adoption. The specific guides used, and the portions relevant from each of them are as follows:
