Note Activity_2.16.840.1.113883.10.20.22.4.202

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SDWG Supported Sample from Implementation Guide

The initial load of this repository in January 2021 includes all examples (figures) from the June 2019 Errata published PDF of C-CDA 2.1 and 2019 release of C-CDA Companion Guide.

These examples were reviewed through the HL7 ballot process. They have not been formally reviewed/approved by the examples task force.

Keywords:

Note Activity

2.16.840.1.113883.10.20.22.4.202

 

Example: Note Activity as Standalone Entry.xml download example view on GitHub

<section>
  <!-- C-CDA 2.1 Procedures Section, entries optional -->
  <templateId root="2.16.840.1.113883.10.20.22.2.7"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.7" extension="2014-06-09"/>
  <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
  <title>Procedures</title>
  <text>
    <list>
      <item ID="ProcedureNote1">
        <paragraph>Dr. Physician - 03 Feb 2014</paragraph>
        <paragraph>Free-text note about procedures which have occurred during this visit.</paragraph>
      </item>
    </list>
  </text>
  <!-- If section were entries required, an additional <entry nullFlavor="NI"> would be required for a Procedure Activity -->
  <!-- Note Activity entry -->
  <entry>
    <act classCode="ACT" moodCode="EVN">
      <templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
      <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName=?ote?
                
        <translation code="28570-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure note" />
      </code>
      <text>
        <reference value="#ProcedureNote1" />
      </text>
      <statusCode code="completed"/>
      <!-- Clinically-relevant time of the note -->
      <effectiveTime value="20140203" />
      <!-- Author Participation -->
      <author>
        <templateId root="2.16.840.1.113883.10.20.22.4.119" />
        <!-- Time note was actually written -->
        <time value="20140204083215-0500" />
        <assignedAuthor>
          <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" />
          <name>Dr. Physician</name>
        </assignedAuthor>
      </author>
      <!-- Reference to encounter -->
      <entryRelationship typeCode="COMP" inversionInd="true">
        <encounter>
          <!-- Encounter ID matches an encounter in the Encounters Section -->
          <id root="1.2.3.4" />
        </encounter>
      </entryRelationship>
    </act>
  </entry>
</section>

Example: Note Activity as entryRelationship to C-CDA Entry.xml download example view on GitHub

<?xml version="1.0" encoding="UTF-8"?>
<section>
  <!-- C-CDA 2.1 Procedures Section -->
  <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
  <templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
  <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="HISTORY OF PROCEDURES"/>
  <title>Procedures</title>
  <text>
    <table>
      <thead>
        <tr>
          <th>Description</th>
          <th>Date and Time (Range)</th>
          <th>Status</th>
          <th>Notes</th>
        </tr>
      </thead>
      <tbody>
        <tr ID="Procedure1">
          <td ID="ProcedureDesc1">Laparoscopic appendectomy</td>
          <td>(03 Feb 2014 09:22am- 03 Feb 2014 11:15am)</td>
          <td>Completed</td>
          <td ID="ProcedureNote1">
            <paragraph>Dr. Physician - 03 Feb 2014</paragraph>
            <paragraph>Free-text note about the procedure.</paragraph>
          </td>
        </tr>
      </tbody>
    </table>
  </text>
  <entry typeCode="DRIV">
    <!-- Procedures should be used for care that directly changes the patient's physical state.-->
    <procedure moodCode="EVN" classCode="PROC">
      <templateId root="2.16.840.1.113883.10.20.22.4.14" />
      <id root="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
      <code code="6025007" displayName="Laparoscopic appendectomy" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
        <originalText>
          <reference value="#ProcedureDesc1" />
        </originalText>
      </code>
      <text>
        <reference value="#Procedure1" />
      </text>
      <statusCode code="completed" />
      <effectiveTime>
        <low value="20140203092205-0700" />
        <high value="20140203111514-0700" />
      </effectiveTime>
      <!-- Note Activity entry -->
      <entryRelationship typeCode="COMP">
        <act classCode="ACT" moodCode="EVN">
          <templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
          <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName=?ote?
                        
            <translation code="28570-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure note" />
          </code>
          <text>
            <reference value="#ProcedureNote1" />
          </text>
          <statusCode code="completed"/>
          <!-- Clinically-relevant time of the note -->
          <effectiveTime value="20140203" />
          <!-- Author Participation -->
          <author>
            <templateId root="2.16.840.1.113883.10.20.22.4.119" />
            <!-- Time note was actually written -->
            <time value="20140204083215-0500" />
            <assignedAuthor>
              <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c" />
              <name>Dr. Physician</name>
            </assignedAuthor>
          </author>
          <!-- Reference to encounter -->
          <entryRelationship typeCode="COMP" inversionInd="true">
            <encounter>
              <!-- Encounter ID matches an encounter in the Encounters Section -->
              <id root="1.2.3.4" />
            </encounter>
          </entryRelationship>
        </act>
      </entryRelationship>
    </procedure>
  </entry>
</section>

Example: RTF Example.xml download example view on GitHub

<section>
  <!--...    -->
  <text>
    <list>
      <item ID="note1">
        <caption>Nursing Note written by Nick Nurse</caption>
        <paragraph>Completed rounds; no incident</paragraph>
      </item>
    </list>
  </text>
  <!-- Note Activity (extra markup removed to focus on <text>) -->
  <entry>
    <act>
      <code>...</code>
      <text mediaType="text/rtf" representation="B64">e1xydGYxXGFuc2lcYW5zaWNwZzEyNTJcZGVmZjBcbm91aWNvbXBhdFxkZWZsYW5nMTAzM3tcZm9udHRibHtcZjBcZm5pbFxmY2hhcnNldDAgQ2FsaWJyaTt9fQ0Ke1wqXGdlbmVyYXRvciBSaWNoZWQyMCA2LjMuOTYwMH1cdmlld2tpbmQ0XHVjMSANClxwYXJkXHNhMjAwXHNsMjc2XHNsbXVsdDFcZjBcZnMyMlxsYW5nOSBDb21wbGV0ZWQgcm91bmRzOyBubyBpbmNpZGVudFxwYXINCn0NCiA=            
                
        <reference value="#note1"/>
      </text>
      <!--...-->
    </act>
  </entry>
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