Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Note Activity

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity Version: 2.1
Draft as of 2023-09-29 Computable Name: NoteActivity
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.202:2016-11-01

The Note Activity represents a clinical note. Notes require authorship, authentication, timing information, and references to other discrete data such as encounters. Similar to the Comment Activity, the Note Activity permits a more specific code to characterize the type of information available in the note. The Note Activity template SHOULD NOT be used in place of a more specific C-CDA entry. Note information included needs to be relevant and pertinent to the information being communicated in the document. When the note information augments data represented in a more specific entry template, the Note Activity can be used in an entryRelationship to the associated standard C-CDA entry. For example, a Procedure Note added as an entryRelationship to a Procedure Activity Procedure entry). The Note Activity template can be used as a standalone entry within a standard C-CDA section (e.g., a note about various procedures which have occurred during a visit as an entry in the Procedures Section) when it does not augment another standard entry. It may also be used to provide additional data about the source of a currently narrative-only section, such as Hospital Course. Finally, if the type of data in the note is not known or no single C-CDA section is appropriate enough, the Note Activity should be placed in a Notes Section. (e.g., a free-text consultation note or a note which includes subjective, objective, assessment, and plan information combined). An alternative is to place the Note Activity as an entryRelationship to an Encounter Activity entry in the Encounters Section, but implementers may wish to group notes categorically into a separate location in CDA documents rather than overloading the Encounters Section.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
... classCode 1..1csFixed Value: ACT
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.202
..... extension 1..1stRequired Pattern: 2016-11-01
.... code 1..1csRequired Pattern: 34109-9
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... translation C0..*CDBinding: Note Types (preferred)
3250-16942: If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
3250-16943: If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
... text 1..1ED
.... mediaType C0..1csBinding: SupportedFileFormats (preferred)
3250-16912: If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
.... reference 1..1TEL
..... nullFlavor 0..0
..... value C1..1url3250-16902: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
... statusCode 1..1CS
... effectiveTime 1..1IVL_TS
.... value 0..1ts
... author 1..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... typeCode 1..1csFixed Value: LA
..... time 1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
..... participantRole C1..1ParticipantRole3250-16930: If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
...... id 1..*II
...... playingEntity 0..1PlayingEntity
....... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... inversionInd 1..1blFixed Value: true
..... negationInd 0..1bl
..... encounter 1..1Encounter
...... id C1..*II3250-16914: If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
... Slices for reference 0..*ReferenceSlice: Unordered, Open by value:externalDocument
.... reference:reference1 0..*Referencereference
..... externalDocument 1..1ExternalDocument
...... id 1..1II
...... code 0..1CD

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Act.code.translationpreferredNote Types
Act.text.mediaTypepreferredSupportedFileFormats

Constraints

IdGradePath(s)DetailsRequirements
3250-16902errorAct.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
:
3250-16912errorAct.text.mediaTypeIf @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
:
3250-16914errorAct.entryRelationship:entryRelationship1.encounter.idIf the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
:
3250-16930errorAct.participant:participant1.participantRoleIf no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
:
3250-16942warningAct.code.translationIf the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
:
3250-16943warningAct.code.translationIf the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.202
..... @extension 1..1stRequired Pattern: 2016-11-01
.... @code 1..1csRequired Pattern: 34109-9
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... translation C0..*CDBinding: Note Types (preferred)
3250-16942: If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
3250-16943: If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
... text 1..1ED
.... @mediaType C0..1csBinding: SupportedFileFormats (preferred)
3250-16912: If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
.... reference 1..1TEL
..... @value C1..1url3250-16902: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
... statusCode 1..1CSBinding: ActStatus (required)
... effectiveTime 1..1IVL_TS
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
... author 1..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LA
..... time C1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
..... participantRole C1..1ParticipantRole3250-16930: If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
...... @classCode 1..1csBinding: RoleClassRoot (required)
...... id 1..*II
...... playingEntity 0..1PlayingEntity
....... @classCode 1..1csBinding: EntityClassRoot (required)
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... @negationInd 0..1bl
..... encounter 1..1Encounter
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: ENC
...... @moodCode 1..1cs
...... id C1..*II3250-16914: If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
... Slices for reference 0..*ReferenceSlice: Unordered, Open by value:externalDocument
.... reference:reference1 0..*Referencereference
..... @typeCode 1..1csBinding: x_ActRelationshipExternalReference (required)
..... externalDocument 1..1ExternalDocument
...... @classCode 1..1csBinding: ActClassDocument (required)
...... id 1..1II
...... code 0..1CDBinding: FHIRDocumentTypeCodes (extensible)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.codeextensibleActCode
Act.code.translationpreferredNote Types
Act.text.mediaTypepreferredSupportedFileFormats
Act.statusCoderequiredActStatus
Act.participant:participant1.typeCoderequiredFixed Value: LA
Act.participant:participant1.participantRole.classCoderequiredRoleClassRoot
Act.participant:participant1.participantRole.playingEntity.classCoderequiredEntityClassRoot
Act.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Act.entryRelationship:entryRelationship1.encounter.classCoderequiredFixed Value: ENC
Act.reference:reference1.typeCoderequiredXActRelationshipExternalReference
Act.reference:reference1.externalDocument.classCoderequiredActClassDocument
Act.reference:reference1.externalDocument.codeextensibleFHIRDocumentTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
3250-16902errorAct.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
:
3250-16912errorAct.text.mediaTypeIf @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
:
3250-16914errorAct.entryRelationship:entryRelationship1.encounter.idIf the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
:
3250-16930errorAct.participant:participant1.participantRoleIf no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
:
3250-16942warningAct.code.translationIf the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
:
3250-16943warningAct.code.translationIf the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
:
81-9371errorAct.participant:participant1.participantRole.playingEntity.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorAct.participant:participant1.participantRole.playingEntity.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10078errorAct.participant:participant1.time**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningAct.participant:participant1.time**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningAct.participant:participant1.time**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningAct.participant:participant1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ivl-ts-centererrorAct.participant:participant1.timeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
pn-no-lserrorAct.participant:participant1.participantRole.playingEntity.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.202
..... @extension 1..1stRequired Pattern: 2016-11-01
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 34109-9
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation C0..*CDBinding: Note Types (preferred)
3250-16942: If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
3250-16943: If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
... @negationInd 0..1bl
... text 1..1ED
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @charset 0..1cs
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (required)
.... @language 0..1cs
.... @mediaType C0..1csBinding: SupportedFileFormats (preferred)
3250-16912: If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
.... @representation 0..1cs
.... data[x] 0..1
..... dataStringstring(st)
..... dataBase64Binarybase64Binary(bin)
.... reference 1..1TEL
..... @value C1..1url3250-16902: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... @use 0..*csBinding: AddressUse (required)
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
... effectiveTime 1..1IVL_TS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 0..1IVXB_TS
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 1..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LA
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time C1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
..... awarenessCode 0..1CE
..... participantRole C1..1ParticipantRole3250-16930: If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
...... @classCode 1..1csBinding: RoleClassRoot (required)
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 0..1PlayingEntity
....... @classCode 1..1csBinding: EntityClassRoot (required)
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... code 0..1CEBinding: EntityCode (extensible)
....... quantity 0..*PQ
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcBirthTime 0..1TSXML Namespace: urn:hl7-org:sdtc
XML: birthTime (urn:hl7-org:sdtc)
....... desc 0..1ED
...... scopingEntity 0..1Entity
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 1..1Encounter
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: ENC
...... @moodCode 1..1cs
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... id C1..*II3250-16914: If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
...... code 0..1CDBinding: ActEncounterCode (extensible)
...... text 0..1ED
...... statusCode 0..1CSBinding: ActStatus (required)
...... effectiveTime 0..1IVL_TS
...... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
...... priorityCode 0..1CEBinding: ActPriority (extensible)
...... subject 0..1Subject
...... specimen 0..*Specimen
...... performer 0..*Performer2
...... author 0..*Author
...... informant 0..*Informant
...... participant 0..*Participant2
...... entryRelationship 0..*EntryRelationship
...... reference 0..*Reference
...... precondition 0..*Precondition
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... Slices for reference 0..*ReferenceSlice: Unordered, Open by value:externalDocument
.... reference:reference1 0..*Referencereference
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipExternalReference (required)
..... seperatableInd 0..1BL
..... externalAct 0..1ExternalAct
..... externalObservation 0..1ExternalObservation
..... externalProcedure 0..1ExternalProcedure
..... externalDocument 1..1ExternalDocument
...... @classCode 1..1csBinding: ActClassDocument (required)
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 1..1II
...... code 0..1CDBinding: FHIRDocumentTypeCodes (extensible)
...... text 0..1ED
...... setId 0..1II
...... versionNumber 0..1INT
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.nullFlavorrequiredNullFlavor
Act.templateId:templateId1.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.code.translationpreferredNote Types
Act.text.nullFlavorrequiredNullFlavor
Act.text.compressionrequiredCompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Act.text.mediaTypepreferredSupportedFileFormats
Act.text.reference.userequiredAddressUse
Act.statusCoderequiredActStatus
Act.effectiveTime.nullFlavorrequiredNullFlavor
Act.effectiveTime.operatorrequiredSetOperator
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.participant:participant1.nullFlavorrequiredNullFlavor
Act.participant:participant1.typeCoderequiredFixed Value: LA
Act.participant:participant1.contextControlCoderequiredFixed Value: OP
Act.participant:participant1.participantRole.classCoderequiredRoleClassRoot
Act.participant:participant1.participantRole.codeextensibleRoleCode
Act.participant:participant1.participantRole.playingEntity.classCoderequiredEntityClassRoot
Act.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Act.participant:participant1.participantRole.playingEntity.codeextensibleEntityCode
Act.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Act.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Act.entryRelationship:entryRelationship1.encounter.classCoderequiredFixed Value: ENC
Act.entryRelationship:entryRelationship1.encounter.codeextensibleActEncounterCode
Act.entryRelationship:entryRelationship1.encounter.statusCoderequiredActStatus
Act.entryRelationship:entryRelationship1.encounter.priorityCodeextensibleActPriority
Act.reference:reference1.nullFlavorrequiredNullFlavor
Act.reference:reference1.typeCoderequiredXActRelationshipExternalReference
Act.reference:reference1.externalDocument.classCoderequiredActClassDocument
Act.reference:reference1.externalDocument.moodCoderequiredFixed Value: EVN
Act.reference:reference1.externalDocument.codeextensibleFHIRDocumentTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
3250-16902errorAct.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
:
3250-16912errorAct.text.mediaTypeIf @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
:
3250-16914errorAct.entryRelationship:entryRelationship1.encounter.idIf the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
:
3250-16930errorAct.participant:participant1.participantRoleIf no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
:
3250-16942warningAct.code.translationIf the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
:
3250-16943warningAct.code.translationIf the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
:
81-9371errorAct.participant:participant1.participantRole.playingEntity.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorAct.participant:participant1.participantRole.playingEntity.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10078errorAct.participant:participant1.time**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningAct.participant:participant1.time**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningAct.participant:participant1.time**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningAct.participant:participant1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ivl-ts-centererrorAct.participant:participant1.timeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
pn-no-lserrorAct.participant:participant1.participantRole.playingEntity.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()

This structure is derived from CDAR2.Act

Summary

Mandatory: 12 elements (9 nested mandatory elements)
Fixed Value: 5 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • The element Act.participant is sliced based on the values of value:participantRole, value:typeCode
  • The element Act.entryRelationship is sliced based on the values of value:encounter, value:typeCode, value:inversionInd
  • The element Act.reference is sliced based on the value of value:externalDocument

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
... classCode 1..1csFixed Value: ACT
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.202
..... extension 1..1stRequired Pattern: 2016-11-01
.... code 1..1csRequired Pattern: 34109-9
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... translation C0..*CDBinding: Note Types (preferred)
3250-16942: If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
3250-16943: If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
... text 1..1ED
.... mediaType C0..1csBinding: SupportedFileFormats (preferred)
3250-16912: If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
.... reference 1..1TEL
..... nullFlavor 0..0
..... value C1..1url3250-16902: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
... statusCode 1..1CS
... effectiveTime 1..1IVL_TS
.... value 0..1ts
... author 1..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... typeCode 1..1csFixed Value: LA
..... time 1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
..... participantRole C1..1ParticipantRole3250-16930: If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
...... id 1..*II
...... playingEntity 0..1PlayingEntity
....... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... inversionInd 1..1blFixed Value: true
..... negationInd 0..1bl
..... encounter 1..1Encounter
...... id C1..*II3250-16914: If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
... Slices for reference 0..*ReferenceSlice: Unordered, Open by value:externalDocument
.... reference:reference1 0..*Referencereference
..... externalDocument 1..1ExternalDocument
...... id 1..1II
...... code 0..1CD

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Act.code.translationpreferredNote Types
Act.text.mediaTypepreferredSupportedFileFormats

Constraints

IdGradePath(s)DetailsRequirements
3250-16902errorAct.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
:
3250-16912errorAct.text.mediaTypeIf @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
:
3250-16914errorAct.entryRelationship:entryRelationship1.encounter.idIf the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
:
3250-16930errorAct.participant:participant1.participantRoleIf no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
:
3250-16942warningAct.code.translationIf the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
:
3250-16943warningAct.code.translationIf the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.202
..... @extension 1..1stRequired Pattern: 2016-11-01
.... @code 1..1csRequired Pattern: 34109-9
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... translation C0..*CDBinding: Note Types (preferred)
3250-16942: If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
3250-16943: If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
... text 1..1ED
.... @mediaType C0..1csBinding: SupportedFileFormats (preferred)
3250-16912: If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
.... reference 1..1TEL
..... @value C1..1url3250-16902: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
... statusCode 1..1CSBinding: ActStatus (required)
... effectiveTime 1..1IVL_TS
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
... author 1..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LA
..... time C1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
..... participantRole C1..1ParticipantRole3250-16930: If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
...... @classCode 1..1csBinding: RoleClassRoot (required)
...... id 1..*II
...... playingEntity 0..1PlayingEntity
....... @classCode 1..1csBinding: EntityClassRoot (required)
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... @negationInd 0..1bl
..... encounter 1..1Encounter
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: ENC
...... @moodCode 1..1cs
...... id C1..*II3250-16914: If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
... Slices for reference 0..*ReferenceSlice: Unordered, Open by value:externalDocument
.... reference:reference1 0..*Referencereference
..... @typeCode 1..1csBinding: x_ActRelationshipExternalReference (required)
..... externalDocument 1..1ExternalDocument
...... @classCode 1..1csBinding: ActClassDocument (required)
...... id 1..1II
...... code 0..1CDBinding: FHIRDocumentTypeCodes (extensible)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.codeextensibleActCode
Act.code.translationpreferredNote Types
Act.text.mediaTypepreferredSupportedFileFormats
Act.statusCoderequiredActStatus
Act.participant:participant1.typeCoderequiredFixed Value: LA
Act.participant:participant1.participantRole.classCoderequiredRoleClassRoot
Act.participant:participant1.participantRole.playingEntity.classCoderequiredEntityClassRoot
Act.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Act.entryRelationship:entryRelationship1.encounter.classCoderequiredFixed Value: ENC
Act.reference:reference1.typeCoderequiredXActRelationshipExternalReference
Act.reference:reference1.externalDocument.classCoderequiredActClassDocument
Act.reference:reference1.externalDocument.codeextensibleFHIRDocumentTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
3250-16902errorAct.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
:
3250-16912errorAct.text.mediaTypeIf @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
:
3250-16914errorAct.entryRelationship:entryRelationship1.encounter.idIf the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
:
3250-16930errorAct.participant:participant1.participantRoleIf no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
:
3250-16942warningAct.code.translationIf the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
:
3250-16943warningAct.code.translationIf the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
:
81-9371errorAct.participant:participant1.participantRole.playingEntity.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorAct.participant:participant1.participantRole.playingEntity.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10078errorAct.participant:participant1.time**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningAct.participant:participant1.time**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningAct.participant:participant1.time**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningAct.participant:participant1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ivl-ts-centererrorAct.participant:participant1.timeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
pn-no-lserrorAct.participant:participant1.participantRole.playingEntity.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act 1..1CDAR2.ActXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @nullFlavor 0..1csBinding: NullFlavor (required)
... @classCode 1..1csFixed Value: ACT
... @moodCode 1..1csFixed Value: EVN
... typeId 0..1II
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.202
..... @extension 1..1stRequired Pattern: 2016-11-01
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 34109-9
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... qualifier 0..*CR
.... translation C0..*CDBinding: Note Types (preferred)
3250-16942: If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
3250-16943: If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
... @negationInd 0..1bl
... text 1..1ED
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @charset 0..1cs
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (required)
.... @language 0..1cs
.... @mediaType C0..1csBinding: SupportedFileFormats (preferred)
3250-16912: If @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
.... @representation 0..1cs
.... data[x] 0..1
..... dataStringstring(st)
..... dataBase64Binarybase64Binary(bin)
.... reference 1..1TEL
..... @value C1..1url3250-16902: This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
..... useablePeriod 0..*
...... useablePeriodIVL_TS
...... useablePeriodEIVL_TS
...... useablePeriodPIVL_TS
...... useablePeriodSXPR_TS
..... @use 0..*csBinding: AddressUse (required)
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
... effectiveTime 1..1IVL_TS
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @value 0..1tsDate Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
.... @operator 0..1csBinding: SetOperator (required)
.... low 0..1IVXB_TS
.... center 0..1TS
.... width 0..1PQ
.... high 0..1IVXB_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 1..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LA
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time C1..1USRealmDateandTimeDTUSFIELDEDBase for all types and resources
..... awarenessCode 0..1CE
..... participantRole C1..1ParticipantRole3250-16930: If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
...... @classCode 1..1csBinding: RoleClassRoot (required)
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 0..*AD
...... telecom 0..*TEL
...... playingDevice 0..1Device
...... playingEntity 0..1PlayingEntity
....... @classCode 1..1csBinding: EntityClassRoot (required)
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... code 0..1CEBinding: EntityCode (extensible)
....... quantity 0..*PQ
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcBirthTime 0..1TSXML Namespace: urn:hl7-org:sdtc
XML: birthTime (urn:hl7-org:sdtc)
....... desc 0..1ED
...... scopingEntity 0..1Entity
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 1..1Encounter
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: ENC
...... @moodCode 1..1cs
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... id C1..*II3250-16914: If the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
...... code 0..1CDBinding: ActEncounterCode (extensible)
...... text 0..1ED
...... statusCode 0..1CSBinding: ActStatus (required)
...... effectiveTime 0..1IVL_TS
...... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
...... priorityCode 0..1CEBinding: ActPriority (extensible)
...... subject 0..1Subject
...... specimen 0..*Specimen
...... performer 0..*Performer2
...... author 0..*Author
...... informant 0..*Informant
...... participant 0..*Participant2
...... entryRelationship 0..*EntryRelationship
...... reference 0..*Reference
...... precondition 0..*Precondition
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... Slices for reference 0..*ReferenceSlice: Unordered, Open by value:externalDocument
.... reference:reference1 0..*Referencereference
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipExternalReference (required)
..... seperatableInd 0..1BL
..... externalAct 0..1ExternalAct
..... externalObservation 0..1ExternalObservation
..... externalProcedure 0..1ExternalProcedure
..... externalDocument 1..1ExternalDocument
...... @classCode 1..1csBinding: ActClassDocument (required)
...... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
...... templateId 0..*II
...... id 1..1II
...... code 0..1CDBinding: FHIRDocumentTypeCodes (extensible)
...... text 0..1ED
...... setId 0..1II
...... versionNumber 0..1INT
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.nullFlavorrequiredNullFlavor
Act.templateId:templateId1.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.code.nullFlavorrequiredNullFlavor
Act.code.translationpreferredNote Types
Act.text.nullFlavorrequiredNullFlavor
Act.text.compressionrequiredCompressionAlgorithm
Act.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Act.text.mediaTypepreferredSupportedFileFormats
Act.text.reference.userequiredAddressUse
Act.statusCoderequiredActStatus
Act.effectiveTime.nullFlavorrequiredNullFlavor
Act.effectiveTime.operatorrequiredSetOperator
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.participant:participant1.nullFlavorrequiredNullFlavor
Act.participant:participant1.typeCoderequiredFixed Value: LA
Act.participant:participant1.contextControlCoderequiredFixed Value: OP
Act.participant:participant1.participantRole.classCoderequiredRoleClassRoot
Act.participant:participant1.participantRole.codeextensibleRoleCode
Act.participant:participant1.participantRole.playingEntity.classCoderequiredEntityClassRoot
Act.participant:participant1.participantRole.playingEntity.determinerCoderequiredFixed Value: INSTANCE
Act.participant:participant1.participantRole.playingEntity.codeextensibleEntityCode
Act.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Act.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Act.entryRelationship:entryRelationship1.encounter.classCoderequiredFixed Value: ENC
Act.entryRelationship:entryRelationship1.encounter.codeextensibleActEncounterCode
Act.entryRelationship:entryRelationship1.encounter.statusCoderequiredActStatus
Act.entryRelationship:entryRelationship1.encounter.priorityCodeextensibleActPriority
Act.reference:reference1.nullFlavorrequiredNullFlavor
Act.reference:reference1.typeCoderequiredXActRelationshipExternalReference
Act.reference:reference1.externalDocument.classCoderequiredActClassDocument
Act.reference:reference1.externalDocument.moodCoderequiredFixed Value: EVN
Act.reference:reference1.externalDocument.codeextensibleFHIRDocumentTypeCodes

Constraints

IdGradePath(s)DetailsRequirements
3250-16902errorAct.text.reference.valueThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:3250-16902).
:
3250-16912errorAct.text.mediaTypeIf @mediaType is present, the text SHALL contain exactly one [1..1] @representation="B64" and mixed content corresponding to the contents of the note (CONF:3250-16912).
:
3250-16914errorAct.entryRelationship:entryRelationship1.encounter.idIf the id does not match an encounter/id from the Encounters Section or encompassingEncounter within the same document and the id does not contain @nullFlavor="NA", then this entry SHALL conform to the Encounter Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
:
3250-16930errorAct.participant:participant1.participantRoleIf no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
:
3250-16942warningAct.code.translationIf the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
:
3250-16943warningAct.code.translationIf the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943).
:
81-9371errorAct.participant:participant1.participantRole.playingEntity.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorAct.participant:participant1.participantRole.playingEntity.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
81-10078errorAct.participant:participant1.time**SHALL** be precise to the day (CONF:81-10078).
:
81-10079warningAct.participant:participant1.time**SHOULD** be precise to the minute (CONF:81-10079).
:
81-10080warningAct.participant:participant1.time**MAY** be precise to the second (CONF:81-10080).
:
81-10081warningAct.participant:participant1.timeIf more precise than day, **SHOULD** include time-zone offset (CONF:81-10081).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ivl-ts-centererrorAct.participant:participant1.timeCenter cannot co-exist with low or high
: center.empty() or (low.empty() and high.empty())
pn-no-lserrorAct.participant:participant1.participantRole.playingEntity.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()

This structure is derived from CDAR2.Act

Summary

Mandatory: 12 elements (9 nested mandatory elements)
Fixed Value: 5 elements
Prohibited: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the values of value:root, value:extension
  • The element Act.participant is sliced based on the values of value:participantRole, value:typeCode
  • The element Act.entryRelationship is sliced based on the values of value:encounter, value:typeCode, value:inversionInd
  • The element Act.reference is sliced based on the value of value:externalDocument

 

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