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ref Template  Annotation Comment

Id 1.3.6.1.4.1.19376.1.5.3.1.4.2 ref (van repository: iheptv-) Geldigheid geldig vanaf 2008‑08‑08
Status review Wordt gereviewed Versielabel
Naam AnnotationComment Weergavenaam Annotation Comment
Omschrijving en-US 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.

See also IHE PCC Wiki Content
Context Parent nodes van template element met id 1.3.6.1.4.1.19376.1.5.3.1.4.2
Classificatie CDA entry level template
Open/gesloten Open (ook andere dan gedefinieerde elementen zijn toegestaan)
Gebruikt door / Gebruikt
Gebruikt door 1 template, Gebruikt 0 templates
Gebruikt door Template-id als Naam Versie
1.3.6.1.4.1.19376.1.3.1.6 Containment Laboratory Observation 2008‑08‑08
Relatie Specialisatie: template 2.16.840.1.113883.10.12.301 (2005‑09‑07)
Voorbeeld
Structure included in the target act using the <entryRelationship> element
<entry>
  <observation classCode="OBS" 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>
Voorbeeld
Structure used in the <component> element when the comment appears within an <organizer>
<entry>
  <organizer>
    <!-- :: -->
    <component typeCode="COMP">
      <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"/>
        <!-- :: -->
      </act>    </component>  </organizer></entry>
Item DT Card Conf Omschrijving Label
hl7:act
 en-US The related statement is an event (moodCode='EVN') describing the act (classCode='ACT') of making an arbitrary comment or providing instruction on the related entry. (AnnotationComment)
@classCode
 1 … 1 F ACT
@moodCode
 1 … 1 F EVN
hl7:templateId
 II 1 … 1 R (AnnotationComment)
@root
 1 … 1 F 2.16.840.1.113883.10.20.1.40
hl7:templateId
 II 1 … 1 R (AnnotationComment)
@root
 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.2
hl7:code
 CD 1 … 1 M en-US 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. (AnnotationComment)
@code
 1 … 1 F 48767-8
@codeSystem
 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
@displayName
 1 … 1 F Annotation Comment
@codeSystemName
 1 … 1 F LOINC
hl7:text
 ED 1 … 1 M en-US The <text> element provides a way to represent the <reference> to the text of the comment in the narrative portion of the document. For CDA, this SHALL be represented as a <reference> element that points to the narrative text section of the CDA. The comment itself is not the act being coded, so it appears in the <text> of the <observation>, not as part of the <code>. For HL7 Version 3 Messages, the <text> element SHALL contain the full narrative text. (AnnotationComment)
hl7:statusCode
 CS 1 … 1 M en-US The code attribute of <statusCode> for all comments must be completed. (AnnotationComment)
@code
 1 … 1 F completed
hl7:author
 0 … 1 R en-US The comment may have an author. (AnnotationComment)
@typeCode
 0 … 1 F AUT
hl7:time
 TS 0 … 1 R en-US The time of the comment creation shall be recorded in the <time> element when the <author> element is present. (AnnotationComment)
hl7:assignedAuthor
 1 … 1 M en-US 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. (AnnotationComment)
@classCode
 0 … 1 F ASSIGNED
hl7:id
 II 1 … 1 R (AnnotationComment)
hl7:addr
 AD 1 … 1 R (AnnotationComment)
hl7:telecom
 TEL 1 … 1 R (AnnotationComment)
Keuze 1 … 2
en-US The author's and/or the organization's name must be present when the <author> element is present.
Elementen om uit te kiezen:
  • hl7:assignedPerson
  • hl7:representedOrganization
hl7:assignedPerson
 0 … 1 R (AnnotationComment)
hl7:representedOrganization
 0 … 1 R (AnnotationComment)