“Act” Clinical Statements
The article The act element, overviews the act clinical act statement XML element and its use in CDA documents.

As noted in the article, the act entry serves as a “catch all” clinical act statement when none of the more specific clinical act statement XML elements (encounter, procedure, observation, substanceAdministrationsupply, or organizer) apply.

C-CDA Concern Act
One relatively special use of the act clinical statement element appears in C-CDA documents in the C-CDA templates for allergies and problems.

The primary clinical act element in the C-CDA allergy and problem sections is observation. There are specific C-CDA templates for a Problem Observation and an Allergy – Intolerance Observation – both of these templates are applied to the observation element.

However, the C-CDA Problem Observation and Allergy Observation templates do not appear directly under the section templates for problems and allergies. Instead, there is an intervening entry template between the section template and the observation template named Problem Concern Act (for the Problems Section) and Allergy Problem Act (for the Allergies Section).

Purpose of the Concern Act
Conceptually, the purpose of the “concern act” is to enable a set of related observations (and possibly other clinical statements) to be viewed together as supporting an overall concern about a given problem or allergy.

This is the language of the C-CDA specification (implementation guide) re. the Problem Concern Act template:

Observations of problems or other clinical statements captured at a point in time are wrapped in a “Concern” act, which represents the ongoing process tracked over time. This allows for binding related observations of problems. For example, the observation of “Acute MI” in 2004 can be related to the observation of “History of MI” in 2006 because they are the same concern. The conformance statements in this section define an outer “problem act” (representing the “Concern”) that can contain a nested “problem observation” or other nested clinical statements.

and this about the Allergy Problem Act template:

This clinical statement act represents a concern relating to a patient’s allergies or adverse events. A concern is a term used when referring to patient’s problems that are related to one another. Observations of problems or other clinical statements captured at a point in time are wrapped in a Allergy Problem Act, or “Concern” act, which represents the ongoing process tracked over time. This outer Allergy Problem Act (representing the “Concern”) can contain nested problem observations or other nested clinical statements relevant to the allergy concern.

Health Concern Tracking
These two C-CDA “concern act” templates are an early-stage manifestation of an important concept called “health concern tracking” which features prominently in the theoretical models that CDA and C-CDA derive from (HL7 v3).

The current version of C-CDA (R1.1) doesn’t support the full “health concern tracking” model. The newer C-CDA R2 that is still being finalized at the time of the writing of this article (refer to the article What is C-CDA 2.0?, for additional information) contains a new template named Health Concern Act that more broadly aligns with the “health concern tracking model”.

Refer to the article Interpreting C-CDA R1.1 concern acts, for a discussion of how to use the relatively limited capabilities of the two concern act templates (Allergy Concern Act and Problem Concern Act) in C-CDA R1.1.

XML Syntax of Concern Acts
The “concern act” templates are applied to an act clinical statement element that sits under the entry element (where we might have otherwise expected the observation elements for the problems or allergies to appear, directly).

That act clinical statement then has one or more entryRelationship elements (refer to the article The entryRelationship element, for more information) that connect it to the observation clinical statements.

The high-level XML syntax outline for concern acts in C-CDA, is shown below:

<section>
   ...
   <entry ...>
      <act ...> <!-- Problem Concern Act -->
         ...
         <entryRelationship ...>
            <observation...> <!-- Problem Observation #1 -->
            </observation>
         </entryRelationship>
         <entryRelationship ...>
            <observation...> <!-- Problem Observation #2 -->
            </observation>
         </entryRelationship>
         ...
      </act>
   </entry>
</section>

Other CDA PRO Know Articles Referenced In This Article