HL7 CCD - 在哪里放置文本细节和注释

Question

I have the need to represent doctors' textual (plain-word) notes, or descriptions, within a HL7 CCD document. I tried to analyze it and I think I got the relation between narrative and entry blocks, but I can't seem to find a way to insert a regular textual note in there without breaking the standard.

Is there any suggestion or guide on this matter?

Answer 1

There is a Comment Activity entry template in the C-CDA spec that is:

templateId: 2.16.840.1.113883.10.20.22.4.64 (open)

Comments are free text data that cannot otherwise be recorded using data elements already defined by this specification. They are not to be used to record information that can be recorded elsewhere. For example, a free text description of the severity of an allergic reaction would not be recorded in a comment.

But you need to verify if your section level template allows to use free text comments. There may be cases when it specifically prohibits this.

Answer 2

There's a proposal for a FHIR template of the CCD document on http://hl7.org/fhir/2016May/ccda/ccda-ccd-composition.html . There are several predefined sections, but you can add your own section to the document. The elements of an additional section are all optional, with the only rule being "A section must at least have one of text, entries, or sub-sections". This means that your doctors notes can be put in that section.text part without breaking the FHIR standard or the rules of the CCD template.

Answer 3

The doctor's note can go in the relevant CCD section such as Problems / Results / Encounters / Plan of Care / etc just like any other entry. Use a of type ST.

Answer 4

This isn't really an appropriate use for a CCD. A CCD is intended as a clinical summary, not a container for chart notes. You should review the other C-CDA document types and see if one of them is a better fit.