Glossary
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 |
Value Set for Act.classCode: Clinical Statement Entry Classes
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 |
typeCode
| SUBJ | Has Subject |
| REFR | Refers to |
| RSON | Has Reason |
moodCode
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 |