Administrative Observations in NEHTA CDA Documents

Nov 16, 2012

All the NEHTA CDA Implementation Guides specify a section called “Administrative Observations”. This is where information that is logically part of the context of the document - administrative type things such as patient age - that don’t fit into the relatively tightly controlled CDA header go. A question has arisen over whether a document has to contain an administrative observation section or not. This arises because of this mapping in the CDA IG:

The key point is that the document says that the section is 1..1 - implying that one must be present. Since we said it’s 1..1, the conformance tests do - correctly - require the section to be present.

But that wasn’t the intent of the design. There’s really no need to have the section at all if there’s entries to go in it (and none of them are mandatory). So there’s been some discussion about relaxing the conformance test in this regard.  However given that we said it’s required, and that it’s been tested to be required, some implementations may have assumed that it’s there, and may have errors if it becomes optional.

So for now, we won’t relax the testing - but it’s reasonably likely that in the future, the section will become explicitly optional, and the testing will follow that.

So I recommend, if you are extracting this admin data from a CDA document - don’t assume that the administrative observations section is present.