[Category: Clinical Act Statements]The
observation clinical act statement appears as an
XML sub-element of three different parent elements in
C-CDA documents:
- entry
- entryRelationship
- component
why is this the case?
Clinical Act StatementsThe article
Clinical act statements, provides an overview of the clinical statements that form the "core" of a
CDA document.
Clinical statements begin with an XML element of:
act,
encounter,
procedure,
observation,
substanceAdministration,
supply, or
organizer.
Clinical statements are contained within
entry elements, which in turn are contained within
section elements, which in turn comprise the structured CDA Body, located in the
XML path:
ClinicalDocument/component/structuredBody.
Clinical statements can also be related to each other via relationship XML elements, such as
entryRelationship. Refer to the article
Act relationship elements, for additional information.
The organizer Clinical Act StatementThe clinical act statement element named
organizer is a bit different than the others. It is used to represent clinical acts that, by their nature, have multiple component parts. The component parts of the
organizer act are each represented within a sub-element of
organizer named
component. Refer to the article
The organizer element, for additional information.
Three Different Contexts for observationGiven the context above, it should now be more clear why the
observation appears in three different contexts (i.e. as an XML sub-element of three different parent XML elements) in C-CDA
templates.
observation appears directly under the
entry element when it is a primary clinical act statement in a section. For example, the Functional Status Section template in C-CDA, supports the direct placement of
observation under
entry - with C-CDA templates such as Functional Status Result Observation, Cognitive Status Result Observation, Assessment Scale Observations, or others being potentially applied to that
observation.
observation appears directly under the
component element when an
organizer clinical act statement is used. In the C-CDA Functional Status Section template the
organizer element may appear directly under an
entry element of the section, with C-CDA templates Functional Status Result Organizer or Cognitive Status Result Organizer applied to it. In that case, the
observation clinical act statements (with C-CDA templates such Functional Status Result Observation and Cognitive Status Result Observation applied to them) within those "organizer act" templates, would appear under
entry/organizer/component.
observation appears directly under the
entryRelationship when it is being related to another clinical act other than an
organizer clinical act (including one
observation clinical act related to another). For example, within the C-CDA Cognitive Status Result Observation (which, as noted above, might appear directly under
entry or
component) there can be an
observation clinical act statement, with the C-CDA Assessment Scale Observation applied to it, placed under
observation/entryRelationship.
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