1.3.6.1.4.1.19376.1.5.3.1.4.2

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Trial.gif Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2

This entry allows for a comment to be supplied with each entry. For CDA this structure is usually included in the target act using the <entryRelationship> element defined in the CDA Schema, but can also be used in the <component> element when the comment appears within an <organizer>. The example below shows recording a comment for an <entry>, and is used as context for the following sections. For HL7 Version 3 Messages, this relationship is represented with the element <sourceOf>, although the remainder of the typecodes and semantics are unchanged.

Any condition or allergy may be the subject of a comment.

Standards
CareStruct HL7 Care Provision Care Structures (DSTU)
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Comments

Specification
Comments Example 
<entry>
  <observation classCode='OBS' moodCode='EVN'>
          ∶
    <entryRelationship typeCode='SUBJ' inversionInd='true'>
      <act classCode='ACT' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.40'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
        <code code='48767-8' displayName='Annotation Comment'
          codeSystem='2.16.840.1.113883.6.1'
          codeSystemName='LOINC' />
        <text><reference value='#comment-2'/></text>
        <statusCode code='completed' />
        <author>
          <time value=''/>
          <assignedAuthor>
            <id root='' extension=''>
            <addr></addr>
            <telecom value='' use=''>
            <assignedPerson><name></name></assignedPerson>
            <representedOrganization><name></name></representedOrganization>
          </assignedAuthor>
        </author>
      </act>
    </entryRelationship>
          ∶
  </observation>
</entry>
<entry>
  <organizer>
    <component typeCode='COMP'>
      <act classCode='ACT' moodCode='EVN'>
        <templateId root='2.16.840.1.113883.10.20.1.40'/>
        <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>
        <code code='48767-8' displayName='Annotation Comment'
          codeSystem='2.16.840.1.113883.6.1'
          codeSystemName='LOINC' />
            :
      </act>
    </component>
  </organizer>
</entry>


<entryRelationship typeCode='SUBJ' inversionInd='true'> or <component typeCode='COMP'/>

A related statement is made about an act, or a cluster or battery of results. In CDA the former shall be recorded inside an <entryRelationship> element occurring at the end of the entry. The containing act is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.

For HL7 Version 3 Messages, the relationship element is <sourceOf>, however the typeCode and inversionInd remain the same.

In the latter case, the comment shall be recorded inside a <commponent> element contained within the <organizer> element.

<act classCode='ACT' moodCode='EVN'>

The related statement is an event (moodCode='EVN') describing the act (classCode='ACT') of making an arbitrary comment or providing instruction on the related entry.

<templateId root='2.16.840.1.113883.10.20.1.40'/>
<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.2'/>

These <templateId> elements identify this <act> as a comment, allowing for validation of the content.

<code code='48767-8' displayName='Annotation Comment' codeSystem='2.16.840.1.113883.6.1' codeSystemName='LOINC' />

The <code> element indicates that this is a comment and shall be recorded as shown above. The codeSystem and code attributes shall use the values specified above.

<text><reference value='#comment-2'/></text>

The <text> element provides a way to represent the <reference> to the text of the comment in the narrative portion of the document. For CDA, this SHALL be represented as a <reference> element that points to the narrative text section of the CDA. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text.

<statusCode code='completed' />

The code attribute of <statusCode> for all comments must be completed.

<author>

The comment may have an author.

The time of the comment creation shall be recorded in the

<assignedAuthor>
 <id root=' ' extension=' '>
 <addr></addr>
 <telecom value=' ' use=' '>

The identifier of the author, and their address and telephone number must be present inside the <id>, <addr> and <telecom> elements when the <author> element is present.

<assignedPerson><name></name></assignedPerson>
<representedOrganization><name></name></representedOrganization>

The author's and/or the organization's name must be present when the <author> element is present.

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