StructureDefinition-2.16.840.1.113883.10.20.22.4.202

Sourcehl7.cda.us.ccda#current:Consolidated CDA Release 2.1 StructureDefinition Publication (v5.0.0)
resourceTypeStructureDefinition
id2.16.840.1.113883.10.20.22.4.202
canonicalhttp://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.202
version2.1
statusactive
publisherHealth Level Seven
nameNoteActivity
titleNote Activity
date2023-08-24T14:33:15+00:00
descriptionThe 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.
jurisdictionsus
fhirVersion5.0.0
kindlogical
abstractfalse
sdTtypehttp://hl7.org/cda/stds/core/StructureDefinition/Act
derivationconstraint
basehttp://hl7.org/cda/stds/core/StructureDefinition/Act
Usages
Name Flags Card. Type Description & Constraints doco
. . Act CDAR2.Act XML Namespace: urn:hl7-org:v3
This logical model cannot be the target of a reference
. . . classCode 1..1 classCode
Fixed Value: ACT
. . . moodCode 1..1 moodCode
Fixed Value: EVN
. . . Slices for templateId 1 .. Slice: Unordered, Open by value:root, value:extension
. . . . templateId:templateId1 1..1 templateId
. . . . . root 1..1 root
Required Pattern: 2.16.840.1.113883.10.20.22.4.202
. . . . . extension 1..1 extension
Required Pattern: 2016-11-01
. . . code 1..1 code
. . . . code 1..1 code
Required Pattern: 34109-9
. . . . codeSystem 1..1 codeSystem
Required Pattern: 2.16.840.1.113883.6.1
. . . . translation C 0..* translation
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 text
. . . . mediaType C 0..1 mediaType
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 reference
. . . . . nullFlavor 0 .. 0
. . . . . value C 1..1 value
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 statusCode
. . . effectiveTime 1..1 effectiveTime
. . . . value 0..1 value
. . . author 1..* http://hl7.org/cda/stds/core/StructureDefinition/Author author
. . . Slices for participant Slice: Unordered, Open by value:participantRole, value:typeCode
. . . . participant:participant1 0..* participant
. . . . . typeCode 1..1 typeCode
Fixed Value: LA
. . . . . time 1..1 http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS time
. . . . . 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..* id
. . . . . . playingEntity 0..1 playingEntity
. . . . . . . name 1..* http://hl7.org/cda/stds/core/StructureDefinition/PN name
. . . Slices for entryRelationship Slice: Unordered, Open by value:encounter, value:typeCode, value:inversionInd
. . . . entryRelationship:entryRelationship1 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: COMP
. . . . . inversionInd 1..1 inversionInd
Fixed Value: true
. . . . . negationInd 0..1 negationInd
. . . . . encounter 1..1 encounter
. . . . . . id C 1..* id
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 (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01) (CONF:3250-16914).
. . . Slices for reference Slice: Unordered, Open by value:externalDocument
. . . . reference:reference1 0..* reference
. . . . . externalDocument 1..1 externalDocument
. . . . . . id 1..1 id
. . . . . . code 0..1 code

doco Documentation for this format

Produced 08 Sep 2023