CCD Glossary

classCode

defines the kind of entry act (kind of clinical statement)

classCode	act	Description
OBS	Observation	Used for representing structured observations
ROIOVL	RegionOfInterest	A clone of the RIM Observation class that represents a region of interest on an image
OBS	ObservationMedia	A clone of the RIM Observation class that represents multimedia that is logically part of the current document
SBADM	SubstanceAdministration	Used for representing medication-related events
SPLY	Supply	Used for representing supply-related events
PROC	Procedure	Used for representing procedures
ENC	Encounter	Used to represent visits
BATTERY or CLUSTER	Organizer	Used to create arbitrary groupings of other CDA entries that share a common context
*see next table	Act	Used when other more specific clones are not appropriate

Code	Definition
ACT (act)	A healthcare service. “A record of something that is being done, has been done, can be done, or is intended or requested to be done.”
ACCM (accommodation)	An accommodation is a service provided for a Person or other LivingSubject in which a place is provided for the subject to reside for a period of time.
CONS (consent)	Represents informed consents and other medico-legal transactions between the patient (or legal guardian) and the provider.
CTTEVENT (clinical trial timepoint event)	An identified point during a clinical trial at which one or more actions are scheduled to be performed (definition mood), or are actually performed (event mood).
INC (incident)	An event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident.
INFRM (inform)	The act of transmitting information and understanding about a topic (or requesting that such information be transmitted) to a subject.
PCPR (care provision)	A patient care provision is the taking on of the responsibility by a performer for the healthcare of a patient or group of patients.
REG (registration)	Represents the act of maintaining information about an entity or role in a registry.
SPCTRT (specimen treatment)	A procedure or treatment performed on a specimen to prepare it for analysis

A code distinguishing whether an Act is conceived of as a factual statement or in some other manner: a command, possibility, goal, etc.

moodCode	Definition
DEF	A definition of a service. Instructions or description of an act.
EVN	An act that actually happens (may be an ongoing act or a documentation of a past act).
GOL	An expectation that is considered to be desirable to occur in the future.
INT	An intention or plan for an act.
PRMS	A commitment to perform an act (may be either solicited or unsolicited).
PRP	A suggestion that an act might be performed. Not an explicit request, and professional responsibility may or may not be present.
RQO	A request act that is specialized for an event request/fulfillment cycle. An order