Id2.16.840.1.113883.10.20.22.2.65Effective Date2016‑11‑01
Statuspending Under pre-publication reviewVersion LabelC-CDA R2.1
NameNotesSectionDisplay NameNotes Section
Description
The Notes Section allow for inclusion of clinical documentation which does not fit precisely within any other C-CDA section. Multiple Notes sections may be included in a document provided they each include different types of note content as indicated by a different section.code. The Notes Section SHOULD NOT be used in place of a more specific a C-CDA section. For example, notes about procedure should be placed within the Procedures Section, not a Notes Section. When a Notes Section is present, Note Activity entries contain structured information about the note information allowing it to be more machine processable.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.2.65
ClassificationCDA Section Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 1 template
Used by as NameVersion
2.16.840.1.113883.3.51.60.3.6Containmentdraft BC CDA Medication Activity (V2) (2.1)2019‑03‑31 19:39:08
2.16.840.1.113883.3.51.60.3.13Containmentpending BC CDA Medication Activities (V2) (2.1)2019‑04‑25 08:05:28
2.16.840.1.113883.3.51.60.3.24Containmentpending BC CDA Immunization Activity (V3) (2.1)2019‑04‑25 09:39:57
2.16.840.1.113883.10.20.22.2.90Containmentdraft Immunization Activity (V3) (2.1)2019‑04‑01 01:57:35
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.202Containmentpending Note Activity (C-CDA R2.1)2016‑11‑01
RelationshipSpecialization: template 2.16.840.1.113883.10.12.201 CDA Section (2005‑09‑07)
ref
ad1bbr-
Example
Note Section Example
<section>
  <!-- Notes Section -->
  <templateId root="2.16.840.1.113883.10.20.22.2.65" extension="2016-11-01"/>  <code code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/>  <title>Consultation Notes</title>  <text>
    <list>
      <item ID="ConsultNote1">
        <paragraph>Dr. Specialist - September 8, 2016</paragraph>        <paragraph>Evaluated patient due to symptoms
of...</paragraph>      </item>    </list>  </text>  <!-- 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="Note">
        <!-- Code must match or be equivalent to section code -->
        <translation code="11488-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Consultation note"/>      </code>      <text>
        <reference value="#ConsultNote1"/>      </text>      <statusCode code="completed"/>      <!-- Clinically-relevant time of the note -->
      <effectiveTime value="20160908"/>      <!--...-->
    </act>  </entry></section>
ItemDTCardConfDescriptionLabel
cda:section
Notedotstion
@ID
0 … 1 MAY contain zero or one [0..1] @ID (CONF:X-X).
@nullFlavor
cs0 … 1 MAY contain zero or one [0..1] @nullFlavor (CONF:X-X).
@classCode
cs0 … 1 MAY contain zero or one [0..1] @classCode (CONF:X-X).
@moodCode
cs0 … 1 MAY contain zero or one [0..1] @moodCode (CONF:X-X).
cda:realmCode
0 … *MAY contain zero or more [0..*] realmCode (CONF:X-X).Notedotstion
cda:typeId
0 … 1MAY contain zero or one [0..1] typeId (CONF:X-X).Notedotstion
cda:templateId
1 … 1MSHALL contain exactly one [1..1] templateId (CONF:3250-16935) such that itCONFdots6935
@root
uid1 … 1F2.16.840.1.113883.10.20.22.2.65CONFdots6936
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.65" (CONF:3250-16936).
@extension
st1 … 1F2016-11-01CONFdots6938
 SHALL contain exactly one [1..1] @extension="2016-11-01" (CONF:3250-16938).
cda:id
0 … 1MAY contain zero or one [0..1] id (CONF:X-X).Notedotstion
cda:code
1 … 1MSHALL contain exactly one [1..1] code, which SHOULD be selected from ValueSet Note Types urn:oid:2.16.840.1.113883.11.20.9.68 (CONF:3250-16892).CONFdots6892
cda:title
1 … 1MSHALL contain exactly one [1..1] title (CONF:3250-16891).

This title should reflect the kind of notes included in this section, corresponding to the code.		CONFdots6891
cda:text
1 … 1MSHALL contain exactly one [1..1] text (CONF:3250-16894).

The narrative SHOULD contain human-readable representations using standard CDA narrative markup of each note to ensure widest compatibility with receivers. While allowed by CDA, the use of <renderMultiMedia> elements, which contain a referencedObject attribute pointing to an <observationMedia> or <regionOfInterest> element in the discrete entries, is discouraged in Note Sections because rendering support for these elements is not widespread.		CONFdots6894
cda:confidentialityCode
0 … 1MAY contain zero or one [0..1] confidentialityCode (CONF:X-X).Notedotstion
cda:languageCode
0 … 1MAY contain zero or one [0..1] languageCode (CONF:X-X).Notedotstion
cda:subject
0 … 1MAY contain zero or one [0..1] subject (CONF:X-X).Notedotstion
cda:author
0 … *MAY contain zero or more [0..*] author (CONF:X-X).Notedotstion
cda:informant
0 … *MAY contain zero or more [0..*] informant (CONF:X-X).Notedotstion
cda:entry
1 … *MSHALL contain at least one [1..*] entry (CONF:3250-16904) such that it

SHALL contain exactly one [1..1] Note Activity (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.202:2016-11-01) (CONF:3250-16905).
Contains 2.16.840.1.113883.10.20.22.4.202 Note Activity (2016‑11‑01)		CONFdots6904
cda:component
0 … *MAY contain zero or more [0..*] component (CONF:X-X).Notedotstion