Clinical Annotation
A text note which also contains information about who made the statement and when. A short comment or message, a post-note. An annotation cannot be edited or deleted. Another annotation can be added to amend any errors.
Clinical Annotation exists as part of the parent context entity or document.
Appears in
- Laboratory Test Observation and Specimen Transportation
- Medical Imaging Reporting
- Medication Statement
- Medical Device and Equipment
- Medication Request, Administration
- Patient Health Concern
- Episode of Care
- Family History
- Encounter
- Clinical Documentation and Annotation
- Observation
- Health Care Service
- Procedure
- Immunization
- Service Request
- Appointment
- Laboratory Test Result Reporting
- Allergy and Intolerance
Constraints
n/a
Stereotype(s)
n/a
Attributes
| Attribute | Type | Multiplicity | Attribute note |
|---|---|---|---|
| Clinical Annotation Type Code | Codeable Concept | 0..1 | Uniquely specifies the type of the care note (e.g., patient instructions, remark, general reason).
Value Set: To be developed. |
| Clinical Annotation Text | Text | 1 | An annotation text content. |
| Clinical Annotation Date Time | Date Time | 0..1 | A date and time when an annotation was created. |
| Clinical Annotation Language Code | Codeable Concept | 0..1 | Uniquely specifies a communication language of the clinical annotation.
Value Set: To be developed. |
Relationships
Contact us
If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.
How to cite:
Canadian Institute for Health Information. Clinical Annotation. Accessed November 02, 2026.
