Generated Narrative: StructureDefinition NoteActivity Name Flags Card. Type Description & Constraints Act <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-text-ref-value )">C 1..1 Act XML Namespace: urn:hl7-org:v3 Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) Constraints: should-text-ref-value #xD; Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension #xD; templateId:note-activity 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.202 #xD; @extension 1..1 st Required Pattern: 2016-11-01 #xD; @classCode 1..1 cs Fixed Value: ACT #xD; @moodCode 1..1 cs Fixed Value: EVN #xD; code <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-translation )">C 1..1 CD Constraints: should-translation #xD; @code 1..1 cs Required Pattern: 34109-9 #xD; @codeSystem 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.6.1 #xD; translation 0..* CD If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942). Binding: Note Types (preferred) #xD; text C 1..1 ED SHOULD reference the portion of section narrative text corresponding to this entry Constraints: 3250-16912 #xD; @mediaType 0..1 cs If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative. Binding: SupportedFileFormats (preferred) #xD; reference <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( value-starts-octothorpe )">C 1..1 TEL Constraints: value-starts-octothorpe #xD; @nullFlavor 0..0 The note activity must reference human-readable content in the narrative, so this reference must not be null. #xD; @value 1..1 url #xD; statusCode 1..1 CS Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. #xD; effectiveTime <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-value-att )">C 1..1 IVL_TS The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time. Constraints: should-value-att #xD; @value 0..1 ts #xD; author 1..* AuthorParticipation Represents the person(s) who wrote the note. #xD; Slices for participant 0..* Participant2 Slice: Unordered, Open by value:typeCode #xD; participant:legalAuthenticator 0..* Participant2 Represents the person(s) legally responsible for the contents of the note. #xD; @typeCode 1..1 cs Fixed Value: LA #xD; time 1..1 USRealmDateTimeInterval Indicates the time of signing the note. #xD; participantRole C 1..1 ParticipantRole Constraints: 3250-16930 #xD; id 1..* II This may be the ID of the note author. If so, no additional information in this participant is required. #xD; playingEntity 0..1 PlayingEntity #xD; name 1..* USRealmPersonNamePNUSFIELDED #xD; Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by exists:encounter #xD; entryRelationship:encounter 0..* EntryRelationship Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter. #xD; @typeCode 1..1 cs Fixed Value: COMP #xD; @inversionInd 1..1 bl Fixed Value: true #xD; @negationInd 0..1 bl To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter. #xD; encounter 1..1 Encounter #xD; id C 1..* II Constraints: 3250-16914 #xD; Slices for reference 0..* Reference Slice: Unordered, Open by exists:externalDocument #xD; reference:externalDocument 0..* Reference Represents an unstructured C-CDA document containing the original contents of the note in the original format. #xD; externalDocument C 1..1 ExternalDocument Constraints: should-code #xD; id 1..1 II #xD; code 0..1 CD #xD; Documentation for this format
HL7 International - Structured Documents
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. The narrative Clinical Notes required in USCDI, along with their associated LOINC codes, are outlined below. These note types are included in the [Note Types Value Set](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.11.20.9.68/expansion), which is bound to Act.code.translation. * Consultation Note (LOINC: 11488-4) * Discharge Summary (LOINC: 18842-5) * History & Physical Note (LOINC: 34117-2) * Procedures Note (LOINC: 28570-0) * Progress Note (LOINC: 11506-3) * Surgical Operation Note (Operative Note) (LOINC: 11504-8) * Emergency Department Note (LOINC: 34111-5)
Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.
If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question
When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.
An II instance must have either a root or an nullFlavor.
A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Identifies the type as an HL7 Registered model
A character string as a unique identifier within the scope of the identifier root.
When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
SHALL contain exactly one [1..1] @classCode="ACT" Act (CONF:3250-16899).
SHALL contain exactly one [1..1] @moodCode="EVN" Event (CONF:3250-16900).
SHALL contain exactly one [1..1] code (CONF:3250-16895).
The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.
This code SHALL contain exactly one [1..1] @code="34109-9" Note (CodeSystem: LOINC urn:oid:2.16.840.1.113883.6.1) (CONF:3250-16940).
Specifies the code system that defines the code.
This code SHALL contain exactly one [1..1] @codeSystem="2.16.840.1.113883.6.1" LOINC (CONF:3250-16941).
If applicable, a version descriptor defined specifically for the given code system.
A name or title for the code, under which the sending system shows the code value to its users.
The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.
The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.
The text or phrase used as the basis for the coding.
Specifies additional codes that increase the specificity of the the primary code.
If the Note Activity is within a narrative-only section (e.g. Hospital Course), the translation MAY match the section code (CONF:3250-16943). If the Note Activity is within a Note Section, the translation SHOULD match or specialize the section code (CONF:3250-16942).
A set of other concept descriptors that translate this concept descriptor into other code systems.
This code SHOULD contain zero or more [0..*] translation, which SHOULD be selected from ValueSet Note Types urn:oid:2.16.840.1.113883.11.20.9.68 DYNAMIC (CONF:3250-16939).
SHOULD reference the portion of section narrative text corresponding to this entry
SHALL contain exactly one [1..1] text (CONF:3250-16896).
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).
mediaType.exists() implies (representation = 'B64' and xmlText.exists())
Indicates whether the raw byte data is compressed, and what compression algorithm was used.
The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.
Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.
For character based information the language property specifies the human language of the text.
If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative.
Identifies the type of the encapsulated data and identifies a method to interpret or render the data.
This text MAY contain zero or one [0..1] @mediaType, which SHOULD be selected from ValueSet SupportedFileFormats urn:oid:2.16.840.1.113883.11.20.7.1 DYNAMIC (CONF:3250-16906).
Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)
This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.
A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.
This text SHALL contain exactly one [1..1] reference (CONF:3250-16897).
If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
value.exists() implies value.startsWith('#')
The note activity must reference human-readable content in the narrative, so this reference must not be null.
This reference SHALL NOT contain [0..0] @nullFlavor (CONF:3250-16920).
This reference SHALL contain exactly one [1..1] @value (CONF:3250-16898).
Specifies the periods of time during which the telecommunication address can be used. For a telephone number, this can indicate the time of day in which the party can be reached on that telephone. For a web address, it may specify a time range in which the web content is promised to be available under the given address.
One or more codes advising a system or user which telecommunication address in a set of like addresses to select for a given telecommunication need.
An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.
Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized.
SHALL contain exactly one [1..1] statusCode (CONF:3250-16916).
The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time.
SHALL contain exactly one [1..1] effectiveTime (CONF:3250-16903).
A quantity specifying a point on the axis of natural time. A point in time is most often represented as a calendar expression.
This effectiveTime SHOULD contain zero or one [0..1] @value (CONF:3250-16917).
A code specifying whether the set component is included (union) or excluded (set-difference) from the set, or other set operations with the current set component and the set as constructed from the representation stream up to the current point.
The arithmetic mean of the interval (low plus high divided by 2). The purpose of distinguishing the center as a semantic property is for conversions of intervals from and to point values.
The difference between high and low boundary. The purpose of distinguishing a width property is to handle all cases of incomplete information symmetrically. In any interval representation only two of the three properties high, low, and width need to be stated and the third can be derived.
Represents the person(s) who wrote the note.
SHALL contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:3250-16913).
MAY contain zero or more [0..*] participant (CONF:3250-16923) such that it
Represents the person(s) legally responsible for the contents of the note.
SHALL contain exactly one [1..1] @typeCode="LA" Legal Authenticator (CONF:3250-16925).
SHALL contain exactly one [1..1] US Realm Date and Time (Interval) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:3250-16926).
SHALL contain exactly one [1..1] participantRole (CONF:3250-16924).
If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present (CONF:3250-16930).
This may be the ID of the note author. If so, no additional information in this participant is required.
This participantRole SHALL contain at least one [1..*] id (CONF:3250-16927).
This participantRole MAY contain zero or one [0..1] playingEntity (CONF:3250-16928).
The playingEntity, if present, SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:3250-16929).
The purpose of this extension is to allow the recording of the subscriber or member of a health plan in cases where the health plan eligibility system has different information on file than the provider does for the patient.
SHOULD contain zero or more [0..*] entryRelationship (CONF:3250-16907) such that it
Links the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter.
SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:3250-16921).
The entryRelationship.inversionInd can be set to "true" to indicate that the relationship should be interpreted as if the roles of the source and target entries were reversed.
SHALL contain exactly one [1..1] @inversionInd="true" (CONF:3250-16922).
The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute in that in all other cases where this attribute is used, the value is fixed at "true", whereas here the value is defaulted to "true", and can be changed to "false" when referencing an entry in the same document. Setting the context conduction to false when referencing an entry in the same document keeps clear the fact that the referenced object retains its original context.
To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd="true" and encounter/id/@nullFlavor="NA". The negationInd + encounter indicate this note is not associated with any encounter.
MAY contain zero or one [0..1] @negationInd (CONF:3250-16931).
SHALL contain exactly one [1..1] encounter (CONF:3250-16908).
This encounter SHALL contain at least one [1..*] id (CONF:3250-16909).
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).
MAY contain zero or more [0..*] reference (CONF:3250-16910) such that it
Represents an unstructured C-CDA document containing the original contents of the note in the original format.
SHALL contain exactly one [1..1] externalDocument (CONF:3250-16911).
This externalDocument SHALL contain exactly one [1..1] id (CONF:3250-16915).
This externalDocument SHOULD contain zero or one [0..1] code (CONF:3250-16918).