ATS 90006.1:2013

Specifies and defines the complete set of data elements proposed for use to support the creation of a valid and interoperable discharge summary instance, and structures the content in a manner that preserves context and meaning under which the contents are created. As such, provides an information framework within which to achieve semantic interoperability, independent of any messaging format, sending/receiving application or data store.

Scope

This Technical Specification describes the logical information model proposed for use in communicating a discharge summary between a healthcare facility and the discharge summary recipients. The Structured Document Template (SDT) defines the allowable set of data items that may be used to facilitate interoperable exchange of discharge summary contents, together with their structure, definition, data type and constraints (including occurrence frequency, value domains and conditions of use).
The contents of this SDT release are restricted to those data items required to support the ‘Core Discharge Summary’ specified in the National E-Health Transition Authority (NEHTA) document e-Discharge Summary Core Information Components, Version 1.1.2. The Core Discharge Summary defines the minimum set of data items that are recommended for implementation in any system that creates and transfers discharge summary information in Australia. This document defines the core data components for exchange that are common to all clinical specialities/domains. It is anticipated that discharge summaries for specific clinical domains will need additional data components to satisfy specialty-specific requirements.
National extensions to the Core Discharge Summary will be considered to support particular specialty areas (e.g. Aged Care, Oncology, Obstetrics, Cardiology, Community Nursing). These extensions will be added to this SDT to form extended sets of nationally-agreed data items for discharge summary interoperable exchange. As such, the SDT will define the allowable set of data items that may be used to facilitate interoperability at the national level.