Note Activity

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.

The narrative Clinical Notes required in USCDI, along with their associated LOINC codes, are outlined below. These note types are included in the Note Types Value Set, which is bound to Act.code.translation.

• Consultation Note (LOINC: 11488-4)
• Discharge Summary (LOINC: 18842-5)
• History & Physical Note (LOINC: 34117-2)
• Procedures Note (LOINC: 28570-0)
• Progress Note (LOINC: 11506-3)
• Surgical Operation Note (Operative Note) (LOINC: 11504-8)
• Emergency Department Note (LOINC: 34111-5)