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Document General Requirements

There are a number of features associated with a document: i) the ability to view documents, ii) the need to acknowledge receipt of a document(s), iii) versioning and compatibility.

Audit Requirements - Clinical

The sending / receiving of Clinical Documents forms part of a patient’s record and as such the audit requirements need to be of an equivalent standard.

ID Description Sender Receiver
FHIR-DOC-01 Documents that are sent or received MUST be logged. Y Y
ID Description Sender Receiver
FHIR-DOC-02 When information from documents has been retrieved or is processed, the local Audit trail SHOULD include entries for the following events:
  • Clinical Information displayed to a user
  • Clinical Information stored (imported) in the local patient record
  • Clinical Information printed.
Y Y
ID Description Sender Receiver
FHIR-DOC-03 The information stored in the audit record SHOULD include:
  • Timestamp
  • Patient NHS Number
  • User identifier and current role identifier
  • Clinical data/document identifier
Y Y

Document Display

ID Description Sender Receiver
FHIR-DOC-04 Sending and Receiving systems MUST provide a function to render the contents of a Document to an authorised user in line with their access rights. Y Y

Composition.type and Document Ontology

ID Description Sender Receiver
FHIR-DOC-05 A Sending system MUST support the use of the SNOMED CT as defined in ValueSet during the creation of a FHIR Document, which has a NHS Digital profile that specifies SNOMED CT for the “Compostion.type” element within the composition resource. Y N
ID Description Sender Receiver
FHIR-DOC-06 A Sending system MUST support the use of the SNOMED CT as defined in ValueSet during the creation of a FHIR Document, which has a NHS Digital profile that specifies SNOMED CT for the “CareSettingType” extension. Y N

General Processing Requirements

The system will need to provide several different views of a document depending on the access rights of individual users and what data they wish to view. The simplest distinction is to:

  1. provide an administrative view of the document which does not display any clinical content (except for document type) and
  2. provide a clinical view which displays all clinical data which may comprise structured coded data and text data.
ID Description Sender Receiver
FHIR-DOC-09 Clinical Data - The system MUST regard all the contents of the Composition.section.text element and the documentReference Binary.content as being the clinical data. Y Y
Tags: fhir

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