As noted in the article What is the high-level CDA document syntax?, clinical statements are contained within entry elements, which in turn are contained within section elements, which in turn comprise the structured CDA Body.

A clinical act statement begins with one of these XML elements, which represent the clinical acts supported in CDA:

  • <act…
  • <encounter…
  • <procedure…
  • <observation…
  • <substanceAdministration…
  • <supply…
  • <organizer…

Common Sub-Elements and Attributes
The article What XML elements and attributes are typically inside a clinical statement?, presents the common XML sub-elements and attributes that are the “core” of the clinical statement.

Related Acts
Potentially nested within the XML elements listed above, are act relationship XML elements that connect clinical acts to each other, such as:

  • <entryRelationship…
  • <component…
  • <precondition…
  • <referenceRange…
  • <reference…

Refer to the article Act relationship elements for additional information about act relationships.

Participation of Roles/Entities
Also potentially nested within the clinical act statements, are various entities (people, places, things), and their roles in the clinical act. Refer to the article Entity XML elements and role XML elements for additional information about roles and entities.

These related roles/entities are connected to the clinical act statement via “participation” XML elements – that connect the roles/entities to the clinical act statement – such as:

  • <subject…
  • <specimen…
  • <consumable…
  • <product…
  • <performer…
  • <author…
  • <informant…
  • <participant…

Refer to the article Participation elements for additional information.

Other CDA PRO Know Articles Referenced In This Article