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active Template  Comment

Id 1.3.6.1.4.1.19376.1.5.3.1.4.2 Effective Date 2013‑12‑20
Status active Active Version Label
Name EntryComment Display Name Comment
Description
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.

Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.2
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 12 templates, Uses 1 template
Used by as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.12 Containment active Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23 link active Section Immunizations 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link active epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link active epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link active epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment active Problem 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link active Problem Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.6 link active Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link active Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 link active Allergies And Intolerances 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link active Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link active Section Allergies and Other Adverse Reactions 2013‑12‑20
Uses as Name Version
2.16.840.1.113883.3.1937.777.11.10.102 Include active epSOS CDA author DYNAMIC
Example
Example
<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/>      <telecom value="" use=""/>      <assignedPerson>
        <name/>      </assignedPerson>
      <representedOrganization>
        <name/>      </representedOrganization>
    </assignedAuthor>
  </author>
</act>
notice There are open issues with this item:
Item DT Card Conf Description Label
hl7:act
R (Entdotsent)
@classCode
cs 1 … 1 F ACT
@moodCode
cs 1 … 1 F EVN
hl7:templateId
II 1 … 1 R (Entdotsent)
@root
uid 1 … 1 F 2.16.840.1.113883.10.20.1.40
hl7:templateId
II 1 … 1 R (Entdotsent)
@root
uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.2
hl7:code
CD 1 … 1 R (Entdotsent)
@code
CONF 0 … 1 F 48767-8
@codeSystem
0 … 1 F 2.16.840.1.113883.6.1 (LOINC)
hl7:statusCode
CS 1 … 1 R (Entdotsent)
@code
CONF 0 … 1 F completed
hl7:text
ED 1 … 1 R (Entdotsent)
hl7:reference
TEL 1 … 1 M (Entdotsent)
@value
1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
Included 0 … * R from 2.16.840.1.113883.3.1937.777.11.10.102 epSOS CDA author (DYNAMIC)
hl7:author
0 … * R (Entdotsent)
 
target
epsos-dataelement-67 draft Author draft epSOS Data Set
@typeCode
cs 0 … 1 F AUT
@contextControlCode
cs 0 … 1 F OP
hl7:functionCode
CE.EPSOS 0 … 1 R R1.10.6
 
target
epsos-dataelement-180 draft Author Role draft epSOS Data Set
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.1 epSOSHealthcareProfessionalRoles (DYNAMIC)
hl7:time
TS.EPSOS.TZ 1 … 1 R The author/time element represents the start time of the author’s participation in the creation of the clinical document. The author/time element SHALL be present. (Entdotsent)
hl7:assignedAuthor
1 … 1 R (Entdotsent)
@classCode
cs 0 … 1 F ASSIGNED
  Schematron assert role red error  
  test @nullFlavor or hl7:assignedPerson or hl7:assignedAuthoringDevice  
  Message If assignedAuthor has an associated representedOrganization with no assignedPerson or assignedAuthoringDevice, then the value for "ClinicalDocument/author/assignedAuthor/id/@nullFlavor" SHALL be "NA" "Not applicable" 2.16.840.1.113883.5.1008 NullFlavor STATIC.  
hl7:id
II.EPSOS 1 … * R HP ID number R1.10.5
 
target
epsos-dataelement-22 draft Author Identification draft epSOS Data Set
@nullFlavor
cs 0 … 1 F NA
hl7:code
CE.EPSOS 0 … 1 R HP Specialty R1.10.7
hl7:addr
AD.EPSOS 1 … * R IHE PCC
hl7:telecom
TEL.EPSOS 1 … * R Attribute @value SHALL contain a URI if element telecom is used. The URI scheme SHALL be one of URLScheme IHE PCC / R1.10.8 / R1.10.8.1 / R1.10.8.2
@use
set_cs 0 … 1  
  CONF
The value of @use shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.40 epSOSTelecomAddress (DYNAMIC)
Choice 0 … 1 Elements to choose from:
hl7:assignedPerson
R (Entdotsent)
@classCode
cs 0 … 1 F PSN
@determinerCode
cs 0 … 1 F INSTANCE
hl7:name
PN 1 … 1 R HP Name IHE PCC
 
target
epsos-dataelement-19 draft Author Full Name draft epSOS Data Set
  Example <name>
  <given>John</given>  <family>Español Smith</family></name>
hl7:family
1 … * M HP Family Name/Surname R1.10.1
 
target
epsos-dataelement-21 draft Family Name/Surname draft epSOS Data Set
hl7:given
1 … * M HP Given Name R1.10.2
 
target
epsos-dataelement-20 draft Given Name draft epSOS Data Set
hl7:prefix
0 … * R HP Prefix R1.10.3
 
target
epsos-dataelement-273 draft Prefix draft epSOS Data Set
hl7:suffix
0 … * R HP Suffix R1.10.4
 
target
epsos-dataelement-274 draft Suffix draft epSOS Data Set
hl7:assignedAuthoringDevice
R Contains 2.16.840.1.113883.3.1937.777.11.10.129 CDA Device (DYNAMIC) (Entdotsent)
hl7:representedOrganization
1 … 1 R Contains 2.16.840.1.113883.3.1937.777.11.10.111 epSOS CDA Organization (DYNAMIC) R1.10.9
 
target
epsos-dataelement-23 draft Author Healthcare Facility draft epSOS Data Set