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ref Template  Annotation Comment

Template 1.3.6.1.4.1.19376.1.5.3.1.4.2 - AnnotationComment ref (aus Repository: iheptv-)
Id 1.3.6.1.4.1.19376.1.5.3.1.4.2
Version gültig ab 2009‑12‑04 Status review Unter Revision
Klassifikation CDA Entry Level Template
Kontext Elternknoten des Template-Element mit Id 1.3.6.1.4.1.19376.1.5.3.1.4.2
Offen/Geschlossen Offen (auch andere als die definierten Elemente sind erlaubt)
Beschreibung 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.
Benutzt von / Benutzt
Benutzt von 2 Templates, Benutzt 0 Templates
Benutzt von Template-Id als Name Version
1.3.6.1.4.1.19376.1.3.1.6 Containment LaboratoryObservation Laboratory Observation 2008‑08‑08
2.16.756.5.30.1.1.1.1.3.9.77.1.10.5 link testObservation test Observation 2016‑03‑24 14:26:02
Beziehung Specialization: Template 2.16.840.1.113883.10.12.303 (2005‑09‑07)
Beispiel
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>
Beispiel
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 Kard Konf Beschreibung 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)
treetree @classCode
1 .. 1 F ACT
treetree @moodCode
1 .. 1 F EVN
treetree hl7:templateId
II 1 .. 1 R (AnnotationComment)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.40
treetree hl7:templateId
II 1 .. 1 R (AnnotationComment)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.2
treetree 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)
treeblank treetree @code
1 .. 1 F 48767-8
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (Logical Observation Identifier Names and Codes)
treeblank treetree @displayName
1 .. 1 F Annotation Comment
treeblank treetree @codeSystemName
1 .. 1 F LOINC
treetree 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)
treetree hl7:statusCode
CS 1 .. 1 M en-US The code attribute of <statusCode> for all comments must be completed. (AnnotationComment)
  CONF
@value ist "completed"
treetree hl7:author
0 .. 1 R en-US The comment may have an author. (AnnotationComment)
treeblank treetree @typeCode
0 .. 1 F AUT
treeblank treetree 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)
treeblank treetree 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)
treeblank treeblank treetree @classCode
0 .. 1 F ASSIGNED
treeblank treeblank treetree hl7:id
II 1 .. 1 R (AnnotationComment)
treeblank treeblank treetree hl7:addr
AD 1 .. 1 R (AnnotationComment)
treeblank treeblank treetree hl7:telecom
TEL 1 .. 1 R (AnnotationComment)
Auswahl min 1 Element(e) und max 2 Element(e). Elemente in der Auswahl:
  • hl7:assignedPerson
  • hl7:representedOrganization
treeblank treeblank treeblank treetree hl7:assignedPerson
0 .. 1 R (AnnotationComment)
treeblank treeblank treeblank treetree hl7:representedOrganization
0 .. 1 R (AnnotationComment)