Clinical Statements
The article Clinical act statements, provides an overview of the clinical statements that form the “core” of a CDA document.

Clinical statements are contained within entry elements, which in turn are contained within section elements, which in turn comprise the structured CDA Body, located in the XML path: ClinicalDocument/component/structuredBody.

Clinical statements begin with an XML element of: act, encounter, procedure, observation, substanceAdministration, supply, or organizer.

Clinical statements can also be related to each other via relationship XML elements, such as entryRelationship. Refer to the article Act relationship elements, for additional information.

The article What XML elements and attributes are typically inside a clinical statement?, overviews some of the sub-elements and attributes that all clinical act statements have in common.

“Act” Clinical Statements
In the model that underlies CDA, the most generic kind of clinical statement is an “act” – the other clinical statements are more specialized forms of an “act”.

From an XML syntax standpoint, the act clinical statement element is used as kind of “miscellaneous / other” bucket. If something doesn’t fit into one of the more specific clinical act statement XML entries, it will be represented with an act entry.

classCode Values for Act Statements
Perhaps the best way to summarize the kind of activities that are represented in CDA documents with the act clinical statement entry is to review the valid values for its classCode attribute (refer to the article The classCode attribute, for more information). These values are shown below:

  • “ACT” – A healthcare service
  • “ACCM” – A service in which a person is provided with a place to live for a period of time
  • “CONS” – Represents informed consents and other medico-legal transactions between the patient (or legal guardian) and the provider
  • “CTTEVENT” - An identified point during a clinical trial at which one or more actions are scheduled to be performed, or are actually performed
  • “INC” – n event that occurred outside of the control of one or more of the parties involved. Includes the concept of an accident
  • “INFRM”- The act of transmitting information and understanding about a topic (or requesting that such information be transmitted) to a subject
  • “PCPR”- A patient care provision is the taking on of the responsibility by a performer for the health care of a patient or group of patients
  • “REG” – Represents the act of maintaining information about an entity or role in a registry
  • “SPCTRT” – A procedure or treatment performed on a specimen to prepare it for analysis

act Sub-Elements and Attributes
The act clinical statement entry has all of the sub-elements and attributes that are common to all clinical act statements, as detailed in the article What XML elements and attributes are typically inside a clinical statement?. This includes the participation elements (refer to the article Participation elements) and act relationship elements (refer to the article Act relationship elements) that are common to all clinical act statements.

In addition, the act entry has an optional languageCode sub-element that indicates the human language in which the clinical act is specified in the document. It is rarely used as most CDA documents are not multilingual.

Other CDA PRO Know Articles Referenced In This Article