1.3.6.1.4.1.19376.1.5.3.1.4.2
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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 Act entry. This structure is included in the target act using the <entryRelationship> element defined in the CDA Schema. The example below shows recording a comment for an <entry>, and is used as context for the following sections.
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
Specification
<entry>
<observation classCode='COND' 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>
|
<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.
<entryRelationship typeCode='SUBJ' inversionInd='true'>
Again, a related statement is made about the condition, allergy or medication. This observation is recorded inside an <entryRelationship> element occurring at the end of the condition or allergy entry. The containing <entry> is the subject (typeCode='SUBJ') of this new observation, which is the inverse of the normal containment structure, thus inversionInd='true'.
<observation classCode='OBS' moodCode='EVN'>
The related statement is an event (moodCode='EVN') making an arbitrary comment or providing instruction on the related entry. As this is simply an observation, so classCode='OBS'.
<code code='48767-8' displayName='Annotation Comment' codeSystem='1.3.6.1.4.1.19376.1.5.3.2' 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 <reference> to the text of the comment in the narrative portion of the document. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>.
<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.