Profile Comparison between http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity vs http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity

Messages

Metadata

Name	Value		Comments
abstract	false
baseDefinition	http://hl7.org/cda/stds/core/StructureDefinition/Act
copyright
date	2024-05-18T00:16:25-05:00	2024-11-21T20:34:36+00:00	Values Differ
description	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 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)	Values Differ
experimental
fhirVersion	5.0.0
jurisdiction
jurisdiction[0]	urn:iso:std:iso:3166#US
kind	logical
name	NoteActivity
publisher	Health Level Seven
purpose
status	draft
title	Note Activity
type	http://hl7.org/cda/stds/core/StructureDefinition/Act
url	http://hl7.org/cda/us/ccda/StructureDefinition/NoteActivity
version	3.0.0	4.0.0-ballot	Values Differ

Structure

Name	L Flags	L Card.	L Type	L Description & Constraints	R Flags	R Card.	R Type	R Description & Constraints	Comments
Act	C	1..1	Act	Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value	C	1..1	Act	Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) should-text-ref-value: SHOULD contain text/reference/@value
nullFlavor		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
realmCode		0..*	CS			0..*	CS
typeId		0..1	II			0..1	II
nullFlavor		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
assigningAuthorityName		0..1	??			0..1	??
displayable		0..1	??			0..1	??
root		1..1	??, ??, ??	Fixed Value: 2.16.840.1.113883.1.3		1..1	??, ??, ??	Fixed Value: 2.16.840.1.113883.1.3
st-simple		1..1	string	Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple		1..1	string	Primitive Type string URL: http://hl7.org/cda/stds/core/StructureDefinition/st-simple
Slices for templateId		1..*	II	Slice: Unordered, Open by value:root, value:extension		1..*	II	Slice: Unordered, Open by value:root, value:extension
classCode		1..1	??	Binding: ?? (required) Fixed Value: ACT		1..1	??	Binding: ?? (required) Fixed Value: ACT
moodCode		1..1	??	Binding: ?? (required) Fixed Value: EVN		1..1	??	Binding: ?? (required) Fixed Value: EVN
negationInd		0..1	??			0..1	??
id		0..*	II			0..*	II
code	C	1..1	CD	Binding: ?? (example) should-translation: SHOULD contain translation	C	1..1	CD	Binding: ?? (example) should-translation: SHOULD contain translation
nullFlavor		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
code		1..1	??	Required Pattern: 34109-9		1..1	??	Required Pattern: 34109-9
codeSystem		1..1	??, ??, ??	Required Pattern: 2.16.840.1.113883.6.1		1..1	??, ??, ??	Required Pattern: 2.16.840.1.113883.6.1
codeSystemName		0..1	??			0..1	??
codeSystemVersion		0..1	??			0..1	??
displayName		0..1	??			0..1	??
sdtcValueSet		0..1	??	XML: valueSet (urn:hl7-org:sdtc)		0..1	??	XML: valueSet (urn:hl7-org:sdtc)
sdtcValueSetVersion		0..1	??	XML: valueSetVersion (urn:hl7-org:sdtc)		0..1	??	XML: valueSetVersion (urn:hl7-org:sdtc)
originalText		0..1	ED			0..1	ED
qualifier		0..*	CR			0..*	CR
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: ?? (preferred)		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: ?? (preferred)
text	C	1..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry 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).	C	1..1	ED	SHOULD reference the portion of section narrative text corresponding to this entry 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).
nullFlavor		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
compression		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
integrityCheck		0..1	??			0..1	??
integrityCheckAlgorithm		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
language		0..1	??			0..1	??
mediaType		0..1	??	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: ?? (preferred)		0..1	??	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: ?? (preferred)
representation		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
xmlText		0..1	??	Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.		0..1	??	Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
reference	C	1..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative	C	1..1	TEL	value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
nullFlavor		0..0				0..0
value		1..1	??			1..1	??
useablePeriod		0..*	IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS			0..*	IVL_TS, EIVL_TS, PIVL_TS, SXPR_TS
use		0..*	??	Binding: ?? (required)		0..*	??	Binding: ?? (required)
thumbnail		0..1	ED			0..1	ED
statusCode		1..1	CS	Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. Binding: ?? (required)		1..1	CS	Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized. Binding: ?? (required)
effectiveTime	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. should-value-att: SHOULD contain @value	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. should-value-att: SHOULD contain @value
nullFlavor		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
value		0..1	??	Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]		0..1	??	Date Format: YYYYMMDDHHMMSS.UUUU[+|-ZZzz]
operator		0..1	??	Binding: ?? (required)		0..1	??	Binding: ?? (required)
low		0..1	IVXB_TS			0..1	IVXB_TS
center		0..1	TS			0..1	TS
width		0..1	PQ			0..1	PQ
high		0..1	IVXB_TS			0..1	IVXB_TS
priorityCode		0..1	CE	Binding: ?? (example)		0..1	CE	Binding: ?? (example)
languageCode		0..1	CS	Binding: ?? (required)		0..1	CS	Binding: ?? (required)
subject		0..1	Subject			0..1	Subject
specimen		0..*	Specimen			0..*	Specimen
performer		0..*	Performer2			0..*	Performer2
author		1..*	??	Represents the person(s) who wrote the note.		1..*	??	Represents the person(s) who wrote the note.
informant		0..*	Informant			0..*	Informant
Slices for participant		0..*	Participant2	Slice: Unordered, Open by value:typeCode		0..*	Participant2	Slice: Unordered, Open by value:typeCode
Slices for entryRelationship		0..*	EntryRelationship	Slice: Unordered, Open by exists:encounter		0..*	EntryRelationship	Slice: Unordered, Open by exists:encounter
Slices for reference		0..*	Reference	Slice: Unordered, Open by exists:externalDocument		0..*	Reference	Slice: Unordered, Open by exists:externalDocument
precondition		0..*	Precondition			0..*	Precondition
sdtcPrecondition2		0..*	Precondition2	XML: precondition2 (urn:hl7-org:sdtc)		0..*	Precondition2	XML: precondition2 (urn:hl7-org:sdtc)
sdtcInFulfillmentOf1		0..*	InFulfillmentOf1	XML: inFulfillmentOf1 (urn:hl7-org:sdtc)		0..*	InFulfillmentOf1	XML: inFulfillmentOf1 (urn:hl7-org:sdtc)
Documentation for this format