Id2.16.840.1.113883.10.20.22.4.202Effective Date2016‑11‑01
Statuspending Under pre-publication reviewVersion LabelC-CDA R2.1
NameNoteActivityDisplay NameNote Activity
Description
The Note Activity represents a clinical note. Notes require authorship, authentication, timing information, and references to other discrete data such as encounters. Similar to the Comment Activity, the Note Activity permits a more specific code to characterize the type of information available in the note. The Note Activity template SHOULD NOT be used in place of a more specific C-CDA entry. Note information included needs to be relevant and pertinent to the information being communicated in the document. When the note information augments data represented in a more specific entry template, the Note Activity can be used in an entryRelationship to the associated standard C-CDA entry. For example, a Procedure Note added as an entryRelationship to a Procedure Activity Procedure entry). The Note Activity template can be used as a standalone entry within a standard C-CDA section (e.g., a note about various procedures which have occurred during a visit as an entry in the Procedures Section) when it does not augment another standard entry. It may also be used to provide additional data about the source of a currently narrative-only section, such as Hospital Course. Finally, if the type of data in the note is not known or no single C-CDA section is appropriate enough, the Note Activity should be placed in a Notes Section. (e.g., a free-text consultation note or a note which includes subjective, objective, assessment, and plan information combined). An alternative is to place the Note Activity as an entryRelationship to an Encounter Activity entry in the Encounters Section, but implementers may wish to group notes categorically into a separate location in CDA documents rather than overloading the Encounters Section.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.202
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 4 templates, Uses 0 templates
Used by as NameVersion
2.16.840.1.113883.10.20.22.2.65Containmentpending Notes Section (C-CDA R2.1)2016‑11‑01
2.16.840.1.113883.10.20.22.2.500linkpending Care Teams Section (C-CDA R2.1)2019‑07‑01
2.16.840.1.113883.10.20.22.4.500Containmentpending Care Team Organizer (C-CDA R2.1)2019‑07‑01
2.16.840.1.113883.10.20.22.4.500.1Containmentpending Care Team Member Act (C-CDA R2.1)2019‑07‑01
RelationshipSpecialization: template 2.16.840.1.113883.10.12.301 CDA Act (2005‑09‑07)
ref
ad1bbr-
Example
Note Activity as entryRelationship to C-CDA Entry
<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="Note">
            <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
Note Activity as Standalone Entry
<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="Note">
        <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
RTF Example
<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>
</section>
ItemDTCardConfDescriptionLabel
cda:act
Notedotsvity
@nullFlavor
cs0 … 1 MAY contain zero or one [0..1] @nullFlavor (CONF:X-X).
@classCode
cs1 … 1RSHALL contain exactly one [1..1] @classCode (CONF:X-X).
@moodCode
cs1 … 1RSHALL contain exactly one [1..1] @moodCode (CONF:X-X).
@negationInd
bl0 … 1 MAY contain zero or one [0..1] @negationInd (CONF:X-X).
cda:realmCode
0 … *MAY contain zero or more [0..*] realmCode (CONF:X-X).Notedotsvity
cda:typeId
0 … 1MAY contain zero or one [0..1] typeId (CONF:X-X).Notedotsvity
cda:templateId
1 … 1MSHALL contain exactly one [1..1] templateId (CONF:3250-16933) such that itCONFdots6933
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.202CONFdots6934
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.202" (CONF:3250-16934).
@extension
st1 … 1F2016-11-01CONFdots6937
 SHALL contain exactly one [1..1] @extension="2016-11-01" (CONF:3250-16937).
cda:id
0 … *MAY contain zero or more [0..*] id (CONF:X-X).Notedotsvity
cda:code
1 … 1MSHALL contain exactly one [1..1] code (CONF:3250-16895).CONFdots6895
@code
CONF1 … 1F34109-9
@codeSystem
1 … 1F2.16.840.1.113883.6.1
cda:translation
0 … *RThis code SHOULD contain zero or more [0..*] translation, which SHALL be selected from ValueSet Note Types urn:oid:2.16.840.1.113883.11.20.9.68 DYNAMIC (CONF:3250-16939) such that it

When the Note Activity is within a Note Section, the code SHOULD match or specialize the section code.

If the Note Activity is within a typically narrative-only section, the code MAY match the section code.
CONFdots6939
cda:text
1 … 1MSHALL contain exactly one [1..1] text (CONF:3250-16896).CONFdots6896
@mediaType
st0 … 1 This text MAY contain zero or one [0..1] @mediaType, which SHOULD be selected from ValueSet SupportedFileFormats urn:oid:2.16.840.1.113883.11.20.7.1 DYNAMIC (CONF:3250-16906).

If the note was originally in another format, such as RTF, this element may also contain the base-64-encoded raw data of the note in addition to a reference to the narrative.
CONFdots6906
cda:reference
1 … 1MThis text SHALL contain exactly one [1..1] reference (CONF:3250-16897).CONFdots6897
@nullFlavor
cs1 … 1RThis reference SHALL NOT contain [0..0] @nullFlavor (CONF:3250-16920).

The note activity must reference human-readable content in the narrative, so this reference must not be null.
CONFdots6920
@value
1 … 1RThis reference SHALL contain exactly one [1..1] @value (CONF:3250-16898).CONFdots6898
cda:statusCode
1 … 1MSHALL contain exactly one [1..1] statusCode (CONF:3250-16916).

Indicates the status of the note. The most common statusCode is completed indicating the note is signed and finalized.
CONFdots6916
cda:effectiveTime
1 … 1MSHALL contain exactly one [1..1] effectiveTime (CONF:3250-16903).

The effectiveTime represents the clinically relevant time of the note. The precise timestamp of creation / updating should be conveyed in author/time.
CONFdots6903
@value
0 … 1 This effectiveTime SHOULD contain zero or one [0..1] @value (CONF:3250-16917).CONFdots6917
cda:priorityCode
0 … 1MAY contain zero or one [0..1] priorityCode (CONF:X-X).Notedotsvity
cda:languageCode
0 … 1MAY contain zero or one [0..1] languageCode (CONF:X-X).Notedotsvity
cda:subject
0 … 1MAY contain zero or one [0..1] subject (CONF:X-X).Notedotsvity
cda:specimen
0 … *MAY contain zero or more [0..*] specimen (CONF:X-X).Notedotsvity
cda:performer
0 … *MAY contain zero or more [0..*] performer (CONF:X-X).Notedotsvity
cda:author
1 … *MSHALL contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:3250-16913).

Represents the person(s) who wrote the note.
CONFdots6913
cda:informant
0 … *MAY contain zero or more [0..*] informant (CONF:X-X).Notedotsvity
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:3250-16923) such that it

Represents the person(s) legally responsible for the contents of the note.
CONFdots6923
@typeCode
cs1 … 1FLACONFdots6925
 SHALL contain exactly one [1..1] @typeCode="LA" Legal Authenticator (CONF:3250-16925).
cda:time
1 … 1MSHALL contain exactly one [1..1] US Realm Date and Time (DT.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.3) (CONF:3250-16926).

Indicates the time of signing the note.
CONFdots6926
cda:participantRole
1 … 1MSHALL contain exactly one [1..1] participantRole (CONF:3250-16924).

If no id matches an author or participant elsewhere in the document, then playingEntity SHALL be present.
CONFdots6924
cda:id
1 … *MThis participantRole SHALL contain at least one [1..*] id (CONF:3250-16927).

This may be the ID of the note author. If so, no additional information in this participant is required.
CONFdots6927
cda:playingEntity
0 … 1This participantRole MAY contain zero or one [0..1] playingEntity (CONF:3250-16928).CONFdots6928
cda:name
1 … *MThe playingEntity, if present, SHALL contain at least one [1..*] US Realm Person Name (PN.US.FIELDED) (identifier: urn:oid:2.16.840.1.113883.10.20.22.5.1.1) (CONF:3250-16929).CONFdots6929
cda:entryRelationship
0 … *RLinks the note to an encounter. If the Note Activity is present within a document containing an encompassingEncounter, then this entryRelationship is optional and the note is associated with the encounter represented by the encompassingEncounter.CONFdots6907
@typeCode
cs1 … 1FCOMPCONFdots6921
 SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:3250-16921).
@inversionInd
bl1 … 1FtrueCONFdots6922
 SHALL contain exactly one [1..1] @inversionInd="true" (CONF:3250-16922).
@negationInd
bl0 … 1 MAY contain zero or one [0..1] @negationInd (CONF:3250-16931).

To communicate that the note is not associated with any encounter, this entryRelationship MAY be included with @negationInd=true and encounter/id/@nullFlavor=NA. The negationInd + encounter indicate this note is not associated with any encounter.
CONFdots6931
 ConstraintSHOULD contain zero or more [0..*] entryRelationship (CONF:3250-16907) such that it
cda:encounter
1 … 1MSHALL contain exactly one [1..1] encounter (CONF:3250-16908).CONFdots6908
cda:id
1 … *MThis encounter SHALL contain at least one [1..*] id (CONF:3250-16909).

If the id does not match an encounter/id from the Encounters Section within the same document and the id does not contain @nullFlavor=NA, then this entry SHALL conform to the Encounter Activity (V3) (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.49:2015-08-01).
CONFdots6909
cda:reference
0 … *MAY contain zero or more [0..*] reference (CONF:3250-16910) such that it

Represents an unstructured C-CDA document containing the original contents of the note in the original format.
CONFdots6910
cda:externalDocument
1 … 1MSHALL contain exactly one [1..1] externalDocument (CONF:3250-16911).CONFdots6911
cda:id
1 … 1MThis externalDocument SHALL contain exactly one [1..1] id (CONF:3250-16915).CONFdots6915
cda:code
0 … 1RThis externalDocument SHOULD contain zero or one [0..1] code (CONF:3250-16918).CONFdots6918
cda:precondition
0 … *MAY contain zero or more [0..*] precondition (CONF:X-X).Notedotsvity
sdtc:precondition2
0 … *MAY contain zero or more [0..*] sdtc:precondition2 (CONF:X-X).Notedotsvity
sdtc:inFulfillmentOf1
0 … *MAY contain zero or more [0..*] sdtc:inFulfillmentOf1 (CONF:X-X).Notedotsvity