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:
- provide an administrative view of the document which does not display any clinical content (except for document type) and
- 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 |
