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ref Template  Comment

Id 1.3.6.1.4.1.19376.1.5.3.1.4.2 Effective Date valid from 2013‑12‑20
Status draft Draft 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 draft Immunizations 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.23 link draft Section Immunizations 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link draft epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link draft epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.5 link draft epSOS-Medication Related Overview 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5 Containment draft Problem 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.2 link draft Problem Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.6 link draft Section Active Problems 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.8 link draft Section History of Past Illness 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.6 link draft Allergies And Intolerances 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.4.5.3 link draft Allergy and Intolerance Concern 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.13 link draft 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 draft 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 Author 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 Author Role 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 Author Identification 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 Author Full Name 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 Family Name/Surname epSOS Data Set
hl7:given
 1 … * M HP Given Name R1.10.2
 
target epsos-dataelement-20 Given Name epSOS Data Set
hl7:prefix
 0 … * R HP Prefix R1.10.3
 
target epsos-dataelement-273 Prefix epSOS Data Set
hl7:suffix
 0 … * R HP Suffix R1.10.4
 
target epsos-dataelement-274 Suffix 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 Author Healthcare Facility epSOS Data Set