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

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

“Encounter” Clinical Statement XML Syntax
The “encounter” clinical act statement represents the interaction between a healthcare provider and patient – such as a doctor office visit, a hospital stay, or a telephone call consultation.

The encounter clinical statement XML entry has nearly all of the sub-elements and attributes that are common to all clinical act statements, as detailed in the article What goes inside a clinical statement XML entry?.

Note, however, that the negationInd sub-element is not supported for encounters. Refer to the article Why can’t encounter and supply clinical statements be negated?, for details.

The classCode attribute for an encounter element is always assigned the value “ENC” and, as this is the default value for encounters, the classCode attribute is generally not explicitly included.

Like with most clinical act statements, the moodCode attribute for an encounter is almost always assigned the value “EVN”. Note that the value “DEF” is not allowed with the encounter element.

The encompassingEncounter element in the CDA Header
There is an “encounter” clinical statement in the XML element named encompassingEncounter in the CDA Header (located in: ClinicalDocument/componentOf/encompassingEncounter). It includes some additional sub-elements that are not part of the encounter clinical act statements in the CDA body.

The encompassingEncounter element in the CDA Header is the correct location for the primary encounter that the CDA document describes – refer to the article The encompassingEncounter element, for additional information. For many CDA documents, this is the only encounter that needs to be documented and thus, most CDA documents don’t have encounter clinical act statements in the CDA Body. Only if there are multiple encounters that are relevant to the document, is there a need to have encounter clinical act statements in the CDA Body.

For additional information about the relationship between the encompassingEncounter in the CDA Header and the encounter clinical act statements in the CDA Body, refer to the article Which encounters go in the CDA Header and which in the CDA Body?.

Other CDA PRO Know Articles Referenced In This Article