1.3.6.1.4.1.19376.1.5.3.1.4.2

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The PCC Wiki Content is used only for development of IHE PCC Content. The Normative content of the PCC Technical Framework and the current supplements can be found at http://www.ihe.net/Technical_Framework/index.cfm#PCC

Comment.gif Comments 1.3.6.1.4.1.19376.1.5.3.1.4.2

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

Standards
CareStruct HL7 Care Provision Care Structures (DSTU)
Uses

See Templates using Comments

Specification
Comments Example 
<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' />
      </act>
    </entryRelationship>
          ∶
  </observation>
</entry>


This profile 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. While CDA and the HL7 V3 Patient Care Structures support more than one comment (called Annotations in the HL7 Patient Care Structures specification), this profile limits the cardinality to one. The example below shows recording a comment for an <entry>, and is used as context for the following sections.

<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.

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