Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build
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
| 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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Act
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Act | CDAR2.Act | XML 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..1 | cs | Fixed Value: ACT | |
| moodCode | 1..1 | cs | Fixed Value: EVN | |
  Slices for templateId | 1..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:templateId1 | 1..1 | II | templateId | |
  root | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.202 | |
  extension | 1..1 | st | Required Pattern: 2016-11-01 | |
| code | 1..1 | CD | ||
| code | 1..1 | cs | Required Pattern: 34109-9 | |
| codeSystem | 1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
 translation | C | 0..* | CD | Binding: 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..1 | ED | ||
| mediaType | C | 0..1 | cs | Binding: 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..1 | TEL | ||
| nullFlavor | 0..0 | |||
| value | C | 1..1 | url | 3250-16902: 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..1 | CS | ||
| effectiveTime | 1..1 | IVL_TS | ||
| value | 0..1 | ts | ||
 author | 1..* | AuthorParticipation | Base for all types and resources | |
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:participantRole, value:typeCode | |
| participant:participant1 | 0..* | Participant2 | participant | |
| typeCode | 1..1 | cs | Fixed Value: LA | |
| time | 1..1 | USRealmDateandTimeDTUSFIELDED | Base for all types and resources | |
 participantRole | C | 1..1 | ParticipantRole | 3250-16930: 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..1 | PlayingEntity | ||
| name | 1..* | USRealmPersonNamePNUSFIELDED | Base for all types and resources | |
| Slices for entryRelationship | 0..* | EntryRelationship | Slice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd | |
| entryRelationship:entryRelationship1 | 0..* | EntryRelationship | entryRelationship | |
| typeCode | 1..1 | cs | Fixed Value: COMP | |
| inversionInd | 1..1 | bl | Fixed Value: true | |
| negationInd | 0..1 | bl | ||
| encounter | 1..1 | Encounter | ||
| id | C | 1..* | II | 3250-16914: 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..* | Reference | Slice: Unordered, Open by value:externalDocument | |
| reference:reference1 | 0..* | Reference | reference | |
| externalDocument | 1..1 | ExternalDocument | ||
| id | 1..1 | II | ||
| code | 0..1 | CD | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Act.code.translation | preferred | Note Types |
| Act.text.mediaType | preferred | SupportedFileFormats |
| Id | Grade | Path(s) | Details | Requirements |
| 3250-16902 | error | Act.text.reference.value | 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). : | |
| 3250-16912 | error | Act.text.mediaType | 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). : | |
| 3250-16914 | error | Act.entryRelationship:entryRelationship1.encounter.id | 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). : | |
| 3250-16930 | error | Act.participant:participant1.participantRole | If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930). : | |
| 3250-16942 | warning | Act.code.translation | If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). : | |
| 3250-16943 | warning | Act.code.translation | If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). : |
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1 based on FHIR 5.0.0. Generated 2023-09-29
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