• Include these codes as defined in http://terminology.hl7.org/CodeSystem/v3-ActRelationshipType version 📍2018-08-12

  Code	Display	Definition
  ACTIMM	active immunization against	Description: The source act is intended to provide active immunity against the effects of the target act (the target act describes an infectious disease)
  ADJUNCT	adjunctive treatment	Description: The source act is intended to offer an additional treatment for the management or cure of a pre-existing adverse situation described by the target act. This is not limited to diseases but can apply to any adverse situation or condition of medical or technical nature. It is not a requirement that the non-adjunctive treatment is explicitly specified.
  APND	is appendage	An addendum (source) to an existing service object (target), containing supplemental information. The addendum is itself an original service object linked to the supplemented service object. The supplemented service object remains in place and its content and status are unaltered.
  ARR	arrival	The relationship that links to a Transportation Act (target) from another Act (source) indicating that the subject of the source Act entered into the source Act by means of the target Transportation act.
  ART	act relationship type	Description: A directed association between a source Act and a target Act. Usage Note: This code should never be transmitted in an instance as the value of ActRelationship.typeCode (attribute)
  AUTH	authorized by	A relationship in which the target act authorizes or certifies the source act.
  BLOCK	blocks	Definition: The source act is performed to block the effects of the target act. This act relationship should be used when describing near miss type incidents where potential harm could have occurred, but the action described in the source act blocked the potential harmful effects of the incident actually occurring.
  BSLN	has baseline	Indicates that the target observation(s) provide an initial reference for the source observation or observation group. UsageConstraints: Both source and target must be Observations or specializations thereof.
  CAUS	is etiology for	Description: An assertion that an act was the cause of another act.This is stronger and more specific than the support link. The source (cause) is typically an observation, but may be any act, while the target may be any act. Examples: a growth of Staphylococcus aureus may be considered the cause of an abscess contamination of the infusion bag was deemed to be the cause of the infection that the patient experienced lack of staff on the shift was deemed to be a supporting factor (proximal factor) causing the patient safety incident where the patient fell out of bed because the bed-sides had not been put up which caused the night patient to fall out of bed
  CHRG	has charge	A relationship that provides an ability to associate a financial transaction (target) as a charge to a clinical act (source). A clinical act may have a charge associated with the execution or delivery of the service. The financial transaction will define the charge (bill) for delivery or performance of the service. Charges and costs are distinct terms. A charge defines what is charged or billed to another organization or entity within an organization. The cost defines what it costs an organization to perform or deliver a service or product.
  CIND	has contra-indication	A contraindication is just a negation of a reason, i.e. it gives a condition under which the action is not to be done. Both, source and target can be any kind of service; target service is in criterion mood. How the strength of a contraindication is expressed (e.g., relative, absolute) is left as an open issue. The priorityNumber attribute could be used.
  COMP	has component	The target act is a component of the source act, with no semantics regarding composition or aggregation implied.
  COMPLY	complies with	Description:The source act complies with, adheres to, conforms to, or is permissible under (in whole or in part) the policy, contract, agreement, law, conformance criteria, certification guidelines or requirement conveyed by the target act. Examples for compliance relationships are: audits of adherence with a security policy, certificate of conformance to system certification requirements, or consent directive in compliance with or permissible under a privacy policy.
  CONCURRENT	concurrent with	A relationship in which the source act's effective time is the same as the target act's effective time. UsageNote: This code is reflexive. Therefore its inverse code is itself.
  COST	has cost	A relationship that provides an ability to associate a financial transaction (target) as a cost to a clinical act (source). A clinical act may have an inherit cost associated with the execution or delivery of the service. The financial transaction will define the cost of delivery or performance of the service. Charges and costs are distinct terms. A charge defines what is charged or billed to another organization or entity within an organization. The cost defines what it costs an organization to perform or deliver a service or product.
  COVBY	covered by	A relationship in which the source act is covered by or is under the authority of a target act. A financial instrument such as an Invoice Element is covered by one or more specific instances of an Insurance Policy.
  CREDIT	has credit	A credit relationship ties a financial transaction (target) to an account (source). A credit, once applied (posted), may have either a positive or negative effect on the account balance, depending on the type of account. An asset account credit will decrease the account balance. A non-asset account credit will decrease the account balance.
  CTRLV	has control variable	A relationship from an Act to a Control Variable. For example, if a Device makes an Observation, this relates the Observation to its Control Variables documenting the device's settings that influenced the observation.
  CURE	curative indication	curative indication
  CURE.ADJ	adjunct curative indication	adjunct curative indication
  DEBIT	has debit	A debit relationship ties a financial transaction (target) to an account (source). A debit, once applied (posted), may have either a positive or negative effect on the account balance, depending on the type of account. An asset account debit will increase the account balance. A non-asset account debit will decrease the account balance.
  DEP	departure	The relationship that links to a Transportation Act (target) from another Act (source) indicating that the subject of the source Act departed from the source Act by means of the target Transportation act.
  DIAG	diagnoses	Description: The source act is intended to help establish the presence of a (an adverse) situation described by the target act. This is not limited to diseases but can apply to any adverse situation or condition of medical or technical nature.
  DOC	documents	The source act documents the target act.
  DRIV	is derived from	Associates a derived Act with its input parameters. E.G., an anion-gap observation can be associated as being derived from given sodium-, (potassium-,), chloride-, and bicarbonate-observations. The narrative content (Act.text) of a source act is wholly machine-derived from the collection of target acts.
  DURING	occurs during	A relationship in which the source act's effective time is wholly within the target act's effective time (including end points, as defined in the act's effective times) UsageNote: Inverse code is SBSEAE
  EAE	ends after end of	A relationship in which the source act ends after the target act ends. UsageNote: Inverse code is EBE
  EAEORECW	ends after or concurrent with end of	A relationship in which the source act's effective time ends after or concurrent with the end of the target act's effective time. Usage Note: Inverse code is EBEORECW
  EAS	ends after start of	A relationship in which the source act ends after the target act starts. UsageNote: Inverse code is SBE
  EASORECWS	ends after or concurrent with start of	A relationship in which the source act's effective time ends after or concurrent with the start of the target act's effective time. Usage Note: Inverse code is EBSORECWS
  EBE	ends before end of	The source Act ends before the end of the target Act (i.e. if we say "ActOne EBE ActTwo", it means that ActOne ends before the end of ActTwo, therefore ActOne is the source and ActTwo is the target). UsageNote: Inverse code is EAE
  EBEORECW	ends before or concurrent with end of	A relationship in which the source act's effective time ends before or concurrent with the end of the target act's effective time. Usage Note: Inverse code is EAEORECW
  EBS	ends before start of	A relationship in which the source act ends before the target act starts. UsageNote: Inverse code is SAE
  EBSORECWS	ends before or concurrent with start of	A relationship in which the source act's effective time ends before or concurrent with the start of the target act's effective time. Usage Note: Inverse code is EASORECWS
  ECW	ends concurrent with	A relationship in which the source act's effective time ends with the end of the target act's effective time. UsageNote: This code is reflexive. Therefore its inverse code is itself.
  ECWS	ends concurrent with start of	The source Act ends when the target act starts (i.e. if we say "ActOne ECWS ActTwo", it means that ActOne ends when ActTwo starts, therefore ActOne is the source and ActTwo is the target). UsageNote: Inverse code is SCWE
  EDU	ends during	A relationship in which the source act ends within the target act's effective time (including end points, as defined in the act's effective times) UsageNote: Inverse code is SBEEAE
  ELNK	episodeLink	Expresses an association that links two instances of the same act over time, indicating that the instance are part of the same episode, e.g. linking two condition nodes for episode of illness; linking two encounters for episode of encounter.
  ENE	ends near end	A relationship in which the source act's effective time ends near the end of the target act's effective time. Near is defined separately as a time interval. Usage Note: Inverse code is ENS
  ENS	ends near start	A relationship in which the source act's effective time ends near the start of the target act's effective time. Near is defined separately as a time interval. Usage Note: Inverse code is ENE
  EVID	provides evidence for	Indicates that the target Act provides evidence in support of the action represented by the source Act. The target is not a 'reason' for the source act, but rather gives supporting information on why the source act is an appropriate course of action. Possible targets might be clinical trial results, journal articles, similar successful therapies, etc. Rationale: Provides a mechanism for conveying clinical justification for non-approved or otherwise non-traditional therapies.
  EXACBY	exacerbated by	Description:The source act is aggravated by the target act. (Example "chest pain" EXACBY "exercise")
  EXPL	has explanation	This is the inversion of support. Used to indicate that a given observation is explained by another observation or condition.
  FLFS	fulfills	The source act fulfills (in whole or in part) the target act. Source act must be in a mood equal or more actual than the target act.
  GEN	has generalization	The generalization relationship can be used to express categorical knowledge about services (e.g., amilorid, triamterene, and spironolactone have the common generalization potassium sparing diuretic).
  GEVL	evaluates (goal)	A goal-evaluation links an observation (intent or actual) to a goal to indicate that the observation evaluates the goal. Given the goal and the observation, a "goal distance" (e.g., goal to observation) can be "calculated" and need not be sent explicitly.
  GOAL	has goal	A goal that one defines given a patient's health condition. Subsequently planned actions aim to meet that goal. Source is an observation or condition node, target must be an observation in goal mood.
  IMM	immunization against	Description: The source act is intented to provide immunity against the effects of the target act (the target act describes an infectious disease)
  INDEPENDENT	independent of time of	The source Act is independent of the time of the target Act. UsageNote: This code is reflexive. Therefore its inverse code is itself.
  INST	instantiates (master)	Used to capture the link between a potential service ("master" or plan) and an actual service, where the actual service instantiates the potential service. The instantiation may override the master's defaults.
  INTF	interfered by	the target act documents a set of circumstances (events, risks) which prevent successful completion, or degradation of quality of, the source Act. UsageNote: This provides the semantics to document barriers to care
  ITEMSLOC	items located	Items located
  LIMIT	limited by	A relationship that limits or restricts the source act by the elements of the target act. For example, an authorization may be limited by a financial amount (up to $500). Target Act must be in EVN.CRIT mood.
  MBR	has member	The target Acts are aggregated by the source Act. Target Acts may have independent existence, participate in multiple ActRelationships, and do not contribute to the meaning of the source. UsageNotes: This explicitly represents the conventional notion of aggregation. The target Act is part of a collection of Acts (no implication is made of cardinality, a source of Acts may contain zero, one, or more member target Acts). It is expected that this will be primarily used with _ActClassRecordOrganizer, BATTERY, and LIST
  META	has metadata	Definition: Indicates that the attributes and associations of the target act provide metadata (for example, identifiers, authorship, etc.) for the source act. Constraint: Source act must have either a mood code that is not "EVN" (event) or its "isCriterion" attribute must set to "true". Target act must be an Act with a mood code of EVN and with isCriterionInd attribute set to "true".
  MFST	is manifestation of	An assertion that a new observation may be the manifestation of another existing observation or action. This assumption is attributed to the same actor who asserts the manifestation. This is stronger and more specific than an inverted support link. For example, an agitated appearance can be asserted to be the manifestation (effect) of a known hyperthyroxia. This expresses that one might not have realized a symptom if it would not be a common manifestation of a known condition. The target (cause) may be any service, while the source (manifestation) must be an observation.
  MITGT	mitigates	The source act removes or lessens the occurrence or effect of the target act.
  MOD	modifies	Definition: Used to link a newer version or 'snapshot' of a business object (source) to an older version or 'snapshot' of the same business object (target). Usage:The identifier of the Act should be the same for both source and target. If the identifiers are distinct, RPLC should be used instead. Name from source to target = "modifiesPrior" Name from target to source = "modifiesByNew"
  MTCH	matches (trigger)	A trigger-match links an actual service (e.g., an observation or procedure that took place) with a service in criterion mood. For example if the trigger is "observation of pain" and pain is actually observed, and if that pain-observation caused the trigger to fire, that pain-observation can be linked with the trigger.
  MTGT.ADJ	adjunct mitigation	adjunct mitigation
  MTREAT	maintenance treatment	Description: The source act is intended to provide long term maintenance improvement or management of a pre-existing adverse situation described by the target act. This is not limited to diseases but can apply to any adverse situation or condition of medical or technical nature.
  NAME	assigns name	Used to assign a "name" to a condition thread. Source is a condition node, target can be any service.
  OBJC	has continuing objective	A desired state that a service action aims to maintain. E.g., keep systolic blood pressure between 90 and 110 mm Hg. Source is an intervention service. Target must be an observation in criterion mood.
  OBJF	has final objective	A desired outcome that a service action aims to meet finally. Source is any service (typically an intervention). Target must be an observation in criterion mood.
  OCCR	occurrence	The source act is a single occurrence of a repeatable target act. The source and target act can be in any mood on the "completion track" but the source act must be as far as or further along the track than the target act (i.e., the occurrence of an intent can be an event but not vice versa).
  OPTN	has option	A relationship between a source Act that provides more detailed properties to the target Act. The source act thus is a specialization of the target act, but instead of mentioning all the inherited properties it only mentions new property bindings or refinements. The typical use case is to specify certain alternative variants of one kind of Act. The priorityNumber attribute is used to weigh refinements as preferred over other alternative refinements. Example: several routing options for a drug are specified as one SubstanceAdministration for the general treatment with attached refinements for the various routing options.
  OREF	references order	Relates either an appointment request or an appointment to the order for the service being scheduled.
  OUTC	has outcome	An observation that should follow or does actually follow as a result or consequence of a condition or action (sometimes called "post-conditional".) Target must be an observation as a goal, risk or any criterion. For complex outcomes a conjunction attribute (AND, OR, XOR) can be used. An outcome link is often inverted to describe an outcome assessment.
  OVERLAP	overlaps with	A relationship in which the source act's effective time overlaps the target act's effective time in any way. UsageNote: This code is reflexive. Therefore its inverse code is itself.
  PALLTREAT	palliates	Description: The source act is intended to provide palliation for the effects of the target act.
  PART	has part	The source Act is a composite of the target Acts. The target Acts do not have an existence independent of the source Act. UsageNote: In UML 1.1, this is a "composition" defined as: "A form of aggregation with strong ownership and coincident lifetime as part of the whole. Parts with non-fixed multiplicity may be created after the composite itself, but once created they live and die with it (i.e., they share lifetimes). Such parts can also be explicitly removed before the death of the composite. Composition may be recursive."
  PASSIMM	passive immunization against	Description: The source act is intended to provide passive immunity against the effects of the target act (the target act describes an infectious disease).
  PERT	has pertinent information	This is a very unspecific relationship from one item of clinical information to another. It does not judge about the role the pertinent information plays.
  PRCN	has pre-condition	A requirement to be true before a service is performed. The target can be any service in criterion mood. For multiple pre-conditions a conjunction attribute (AND, OR, XOR) is applicable.
  PREV	has previous instance	A relationship in which the target act is a predecessor instance to the source act. Generally each of these instances is similar, but no identical. In healthcare coverage it is used to link a claim item to a previous claim item that might have claimed for the same set of services.
  PRYLX	prophylaxis of	Description: The source act is intended to reduce the risk of of an adverse situation to emerge as described by the target act. This is not limited to diseases but can apply to any adverse situation or condition of medical or technical nature.
  QUALF	has qualifier	The target observation qualifies (refines) the semantics of the source observation. UsageNote: This is not intended to replace concept refinement and qualification via vocabulary. It is used when there are multiple components which together provide the complete understanding of the source Act.
  RACT
  RCHAL	re-challenge	Description:A relationship in which the target act is carried out to determine whether an effect attributed to the source act can be recreated.
  RCVY	recovers	Definition: The source act is performed to recover from the effects of the target act.
  REFR	refers to	A relationship in which the target act is referred to by the source act. This permits a simple reference relationship that distinguishes between the referent and the referee.
  REFV	has reference values	Reference ranges are essentially descriptors of a class of result values assumed to be "normal", "abnormal", or "critical." Those can vary by sex, age, or any other criterion. Source and target are observations, the target is in criterion mood. This link type can act as a trigger in case of alarms being triggered by critical results.
  RELVBY	relieved by	Description:The source act is wholly or partially alleviated by the target act. (Example "chest pain" RELVBY "sublingual nitroglycerin administration")
  REV	reverses	A relationship between a source Act that seeks to reverse or undo the action of the prior target Act. Example: A posted financial transaction (e.g., a debit transaction) was applied in error and must be reversed (e.g., by a credit transaction) the credit transaction is identified as an undo (or reversal) of the prior target transaction. Constraints: the "completion track" mood of the target Act must be equally or more "actual" than the source act. I.e., when the target act is EVN the source act can be EVN, or any INT. If the target act is INT, the source act can be INT.
  RISK	has risk	A noteworthy undesired outcome of a patient's condition that is either likely enough to become an issue or is less likely but dangerous enough to be addressed.
  RPLC	replaces	A replacement source act replaces an existing target act. The state of the target act being replaced becomes obselete, but the act is typically still retained in the system for historical reference. The source and target must be of the same type.
  RSON	has reason	Description: The reason or rationale for a service. A reason link is weaker than a trigger, it only suggests that some service may be or might have been a reason for some action, but not that this reason requires/required the action to be taken. Also, as opposed to the trigger, there is no strong timely relation between the reason and the action. As well as providing various types of information about the rationale for a service, the RSON act relationship is routinely used between a SBADM act and an OBS act to describe the indication for use of a medication. Child concepts may be used to describe types of indication. Discussion: In prior releases, the code "SUGG" (suggests) was expressed as "an inversion of the reason link." That code has been retired in favor of the inversion indicator that is an attribute of ActRelationship.
  SAE	starts after end of	A relationship in which the source act starts after the target act ends. UsageNote: Inverse code is EBS
  SAEORSCWE	starts after or concurrent with end of	A relationship in which the source act's effective time starts after or concurrent with the end of the target act's effective time. Usage Note: Inverse code is SBEORSCWE
  SAS	starts after start of	The source Act starts after the start of the target Act (i.e. if we say "ActOne SAS ActTwo", it means that ActOne starts after the start of ActTwo, therefore ActOne is the source and ActTwo is the target). UsageNote: Inverse code is SBS
  SASEAE	starts after start of, ends after end of	The source Act starts after start of the target Act and ends after end of the target Act. UsageNote: Inverse code is SBSEBE
  SASECWE	starts after start of, ends with	The source Act starts after start of the target Act, and ends with the target Act. UsageNote: Inverse code is SBSECWE
  SASORSCW	starts after or concurrent with start of	A relationship in which the source act's effective time starts after or concurrent with the start of the target act's effective time. Usage Note: Inverse code is SBSORSCW
  SASSBEEAS	start after start of, contains end of	The source Act start after the start of the target Act, and contains the end of the target Act. UsageNote: Inverse code is SBSEASEBE
  SBE	starts before end of	The source Act starts before the end of the target Act (i.e. if we say "ActOne SBE ActTwo", it means that ActOne starts before the end of ActTwo, therefore ActOne is the source and ActTwo is the target). UsageNote: Inverse code is EAS
  SBEEAE	contains end of	The source Act contains the end of the target Act. UsageNote: Inverse code is EDU
  SBEORSCWE	starts before or concurrent with end of	A relationship in which the source act's effective time starts before or concurrent with the end of the target act's effective time. Usage Note: Inverse code is SAEORSCWE
  SBS	starts before start of	A relationship in which the source act begins before the target act begins. UsageNote: Inverse code is SAS
  SBSEAE	contains time of	The source Act contains the time of the target Act. UsageNote: Inverse code is DURING
  SBSEAS	contains start of	The source Act contains the start of the target Act. UsageNote: Inverse code is SDU
  SBSEASEBE	contains start of, ends before end of	The source Act contains the start of the target Act, and ends before the end of the target Act. UsageNote: Inverse code is SASSBEEAS
  SBSEBE	starts before start of, ends before end of	The source Act starts before the start of the target Act, and ends before the end of the target Act. UsageNote: Inverse code is SASEAE
  SBSECWE	starts before start of, ends with	The source Act starts before the start of the target Act, and ends with the target Act. UsageNote: Inverse code is SASECWE
  SBSORSCW	starts before or concurrent with start of	A relationship in which the source act's effective time starts before or concurrent with the start of the target act's effective time. Usage Note: Inverse code is SASORSCW
  SCH	schedules request	Associates a specific time (and associated resources) with a scheduling request or other intent.
  SCW	starts concurrent with	A relationship in which the source act's effective time starts with the start of the target act's effective time. UsageNote: This code is reflexive. Therefore its inverse code is itself.
  SCWE	starts concurrent with end of	The source Act starts when the target act ends (i.e. if we say "ActOne SCWE ActTwo", it means that ActOne starts when ActTwo ends, therefore ActOne is the source and ActTwo is the target). UsageNote: Inverse code is SBSECWS
  SCWSEAE	starts with, ends after end of	The source Act starts with the target Act, and ends after the end of the target Act.
  SCWSEBE	starts with. ends before end of	The source Act starts with.the target Act and ends before the end of the target Act. UsageNote: Inverse code is SCWSEAE
  SDU	starts during	A relationship in which the source act starts within the target act's effective time (including end points, as defined in the act's effective times) UsageNote: Inverse code is SBSEAS
  SEQL	is sequel	An act relationship indicating that the source act follows the target act. The source act should in principle represent the same kind of act as the target. Source and target need not have the same mood code (mood will often differ). The target of a sequel is called antecedent. Examples for sequel relationships are: revision, transformation, derivation from a prototype (as a specialization is a derivation of a generalization), followup, realization, instantiation.
  SNE	starts near end	A relationship in which the source act's effective time starts near the end of the target act's effective time. Near is defined separately as a time interval. Usage Note: Inverse code is SNS
  SNS	starts near start	A relationship in which the source act's effective time starts near the start of the target act's effective time. Near is defined separately as a time interval. Usage Note: Inverse code is SNE
  SPRT	has support	Used to indicate that an existing service is suggesting evidence for a new observation. The assumption of support is attributed to the same actor who asserts the observation. Source must be an observation, target may be any service (e.g., to indicate a status post).
  SPRTBND	has bounded support	A specialization of "has support" (SPRT), used to relate a secondary observation to a Region of Interest on a multidimensional observation, if the ROI specifies the true boundaries of the secondary observation as opposed to only marking the approximate area. For example, if the start and end of an ST elevation episode is visible in an EKG, this relation would indicate the ROI bounds the "ST elevation" observation -- the ROI defines the true beginning and ending of the episode. Conversely, if a ROI simply contains ST elevation, but it does not define the bounds (start and end) of the episode, the more general "has support" relation is used. Likewise, if a ROI on an image defines the true bounds of a "1st degree burn", the relation "has bounded support" is used; but if the ROI only points to the approximate area of the burn, the general "has support" relation is used.
  STEP	has step	A collection of sub-services as steps or subtasks performed for the source service. Services may be performed sequentially or concurrently. UsageNotes: Sequence of steps may be indicated by use of _ActRelationshipTemporallyPertains, as well as via ActRelationship.sequenceNumber, ActRelationship.pauseQuantity, Target.priorityCode. OpenIssue: Need Additional guidelines on when each approach should be used.
  SUBJ	has subject	Relates an Act to its subject Act that the first Act is primarily concerned with. Examples The first Act may be a ControlAct manipulating the subject Act The first act is a region of interest (ROI) that defines a region within the subject Act. The first act is a reporting or notification Act, that echos the subject Act for a specific new purpose. Constraints An Act may have multiple subject acts. Rationale The ActRelationshipType "has subject" is similar to the ParticipationType "subject", Acts that primarily operate on physical subjects use the Participation, those Acts that primarily operate on other Acts (other information) use the ActRelationship.
  SUCC	succeeds	Definition: A new act that carries forward the intention of the original act, but does not completely replace it. The status of the predecessor act must be 'completed'. The original act is the target act and the successor is the source act.
  SUGG
  SUMM	summarized by	An act that contains summary values for a list or set of subordinate acts. For example, a summary of transactions for a particular accounting period.
  SYMP	symptomatic relief	Description: The source act is intented to provide symptomatic relief for the effects of the target act.
  TREAT	treats	Description: The source act is intended to improve a pre-existing adverse situation described by the target act. This is not limited to diseases but can apply to any adverse situation or condition of medical or technical nature.
  TRIG	has trigger	A pre-condition that if true should result in the source Act being executed. The target is in typically in criterion mood. When reported after the fact (i.e. the criterion has been met) it may be in Event mood. A delay between the trigger and the triggered action can be specified. Discussion: This includes the concept of a required act for a service or financial instrument such as an insurance plan or policy. In such cases, the trigger is the occurrence of a specific condition such as coverage limits being exceeded.
  UPDT	updates (condition)	A condition thread relationship specifically links condition nodes together to form a condition thread. The source is the new condition node and the target links to the most recent node of the existing condition thread.
  USE	uses	Indicates that the source act makes use of (or will make use of) the information content of the target act. UsageNotes: A usage relationship only makes sense if the target act is authored and occurs independently of the source act. Otherwise a simpler relationship such as COMP would be appropriate. Rationale: There is a need when defining a clinical trial protocol to indicate that the protocol makes use of other protocol or treatment specifications. This is stronger than the assertion of "references". References may exist without usage, and in a clinical trial protocol is common to assert both: what other specifications does this trial use and what other specifications does it merely reference.
  VALUE	has value	Description:Indicates that the target Act represents the result of the source observation Act. FormalConstraint: Source Act must be an Observation or specialization there-of. Source Act must not have the value attribute specified UsageNote: This relationship allows the result of an observation to be fully expressed as RIM acts as opposed to being embedded in the value attribute. For example, sending a Document act as the result of an imaging observation, sending a list of Procedures and/or other acts as the result of a medical history observation. The valueNegationInd attribute on the source Act has the same semantics of "negated finding" when it applies to the target of a VALUE ActRelationship as it does to the value attribute. On the other hand, if the ActRelationship.negationInd is true for a VALUE ActRelationship, that means the specified observation does not have the indicated value but does not imply a negated finding. Because the semantics are extremely close, it is recommended that Observation.valueNegationInd be used, not ActRelationship.negationInd. OpenIssue: The implications of negationInd on ActRelationship and the valueNegationind on Observation.
  VRXCRPT	Excerpt verbatim	The source is a direct quote from the target.
  XCRPT	Excerpts	The source is an excerpt from the target.
  XFRM	transformation	Used when the target Act is a transformation of the source Act. (For instance, used to show that a CDA document is a transformation of a DICOM SR document.)
  _ActClassTemporallyPertains	ActClassTemporallyPertains	ActClassTemporallyPertains
  _ActRelationshipAccounting	ActRelationshipAccounting	Codes that describe the relationship between an Act and a financial instrument such as a financial transaction, account or invoice element.
  _ActRelationshipConditional	ActRelationshipConditional	Specifies under what circumstances (target Act) the source-Act may, must, must not or has occurred
  _ActRelationshipCostTracking	ActRelationshipCostTracking	Expresses values for describing the relationship relationship between an InvoiceElement or InvoiceElementGroup and a billable act.
  _ActRelationshipPosting	ActRelationshipPosting	Expresses values for describing the relationship between a FinancialTransaction and an Account.
  _ActRelationshipTemporallyPertains	ActRelationshipTemporallyPertains	Abstract collector for ActRelationhsip types that relate two acts by their timing.
  _ActRelationshipTemporallyPertainsApproximates	ActRelationshipTemporallyPertainsApproximates	Abstract collector for ActRelationship types that relate two acts by their approximate timing.
  _ActRelationsipObjective	Act Relationsip Objective	The target act is a desired outcome of the source act. Source is any act (typically an intervention). Target must be an observation in criterion mood.

This value set expansion contains 137 concepts.

                       Usage Note: This code should never be transmitted in an instance as the value of ActRelationship.typeCode (attribute)

                       UsageConstraints: Both source and target must be Observations or specializations thereof.

                       Examples:
                    

                    
                       a growth of Staphylococcus aureus may be considered the cause of an abscess
                       contamination of the infusion bag was deemed to be the cause of the infection that the patient experienced
                       lack of staff on the shift was deemed to be a supporting factor (proximal factor) causing the patient safety incident where the patient fell out of bed because the  bed-sides had not been put up which caused the night patient to fall out of bed

                    The financial transaction will define the charge (bill) for delivery or performance of the service.

                    Charges and costs are distinct terms.  A charge defines what is charged or billed to another organization or entity within an organization.  The cost defines what it costs an organization to perform or deliver a service or product.

                    Examples for compliance relationships are: audits of adherence with a security policy, certificate of conformance to system certification requirements, or consent directive in compliance with or permissible under a privacy policy.

                       UsageNote: This code is reflexive.  Therefore its inverse code is itself.

                    The financial transaction will define the cost of delivery or performance of the service.

                    Charges and costs are distinct terms.  A charge defines what is charged or billed to another organization or entity within an organization.  The cost defines what it costs an organization to perform or deliver a service or product.

                       UsageNote: Inverse code is SBSEAE

                       UsageNote: Inverse code is EBE

                       Usage Note: Inverse code is EBEORECW

                       UsageNote: Inverse code is SBE

                       Usage Note: Inverse code is EBSORECWS

                       UsageNote: Inverse code is EAE

                       Usage Note: Inverse code is EAEORECW

                       UsageNote: Inverse code is SAE

                       Usage Note: Inverse code is EASORECWS

                       UsageNote: This code is reflexive.  Therefore its inverse code is itself.

                       UsageNote: Inverse code is SCWE

                       UsageNote: Inverse code is SBEEAE

                       Usage Note: Inverse code is ENS

                       Usage Note: Inverse code is ENE

                       Rationale: Provides a mechanism for conveying clinical justification for non-approved or otherwise non-traditional therapies.

                       UsageNote: This code is reflexive.  Therefore its inverse code is itself.

                       UsageNote: This provides the semantics to document barriers to care

                       UsageNotes: This explicitly represents the conventional notion of aggregation.  The target Act is part of a collection of Acts (no implication is made of cardinality, a source of Acts may contain zero, one, or more member target Acts).

                    It is expected that this will be primarily used with _ActClassRecordOrganizer, BATTERY, and LIST

                       Constraint:  Source act must have either a mood code that is not "EVN" (event) or its "isCriterion" attribute must set to "true".  Target act must be an Act with a mood code of EVN and with isCriterionInd attribute set to "true".

                       Usage:The identifier of the Act should be the same for both source and target. If the identifiers are distinct, RPLC should be used instead.

                    Name from source to target = "modifiesPrior"

                    Name from target to source = "modifiesByNew"

                    The source act thus is a specialization of the target act, but instead of mentioning all the inherited properties it only mentions new property bindings or refinements.

                    The typical use case is to specify certain alternative variants of one kind of Act. The priorityNumber attribute is used to weigh refinements as preferred over other alternative refinements.

                    Example: several routing options for a drug are specified as one SubstanceAdministration for the general treatment with attached refinements for the various routing options.

                       UsageNote: This code is reflexive.  Therefore its inverse code is itself.

                       UsageNote: In UML 1.1, this is a "composition" defined as: 
                       "A form of aggregation with strong ownership and coincident lifetime as part of the whole. Parts with non-fixed multiplicity may be created after the composite itself, but once created they live and die with it (i.e., they share lifetimes). Such parts can also be explicitly removed before the death of the composite. Composition may be recursive."

                       UsageNote: This is not intended to replace concept refinement and qualification via vocabulary.  It is used when there are multiple components which together provide the complete understanding of the source Act.

                    Example: A posted financial transaction (e.g., a debit transaction) was applied in error and must be reversed (e.g., by a credit transaction) the credit transaction is identified as an undo (or reversal) of the prior target transaction.

                    Constraints: the "completion track" mood of the target Act must be equally or more "actual" than the source act. I.e., when the target act is EVN the source act can be EVN, or any INT. If the target act is INT, the source act can be INT.

                       Discussion: In prior releases, the code "SUGG" (suggests) was expressed as "an inversion of the reason link." That code has been retired in favor of the inversion indicator that is an attribute of ActRelationship.

                       UsageNote: Inverse code is EBS

                       Usage Note: Inverse code is SBEORSCWE

                       UsageNote: Inverse code is SBS

                       UsageNote: Inverse code is SBSEBE

                       UsageNote: Inverse code is SBSECWE

                       Usage Note: Inverse code is SBSORSCW

                       UsageNote: Inverse code is SBSEASEBE

                       UsageNote: Inverse code is EAS

                       UsageNote: Inverse code is EDU

                       Usage Note: Inverse code is SAEORSCWE

                       UsageNote: Inverse code is SAS

                       UsageNote: Inverse code is DURING

                       UsageNote: Inverse code is SDU

                       UsageNote: Inverse code is SASSBEEAS

                       UsageNote: Inverse code is SASEAE

                       UsageNote: Inverse code is SASECWE

                       Usage Note: Inverse code is SASORSCW

                       UsageNote: This code is reflexive.  Therefore its inverse code is itself.

                       UsageNote: Inverse code is SBSECWS

                       UsageNote: Inverse code is SCWSEAE

                       UsageNote: Inverse code is SBSEAS

                       Usage Note: Inverse code is SNS

                       Usage Note: Inverse code is SNE

                       UsageNotes: Sequence of steps may be indicated by use of _ActRelationshipTemporallyPertains, as well as via  ActRelationship.sequenceNumber, ActRelationship.pauseQuantity, Target.priorityCode.

                    
                       OpenIssue: Need Additional guidelines on when each approach should be used.

                    Examples

                    
                       
                          The first Act may be a ControlAct manipulating the subject Act 

                       
                       
                          The first act is a region of interest (ROI) that defines a region within the subject Act.

                       
                       
                          The first act is a reporting or notification Act, that echos the subject Act for a specific new purpose.

                       
                    
                    Constraints

                    An Act may have multiple subject acts.

                    Rationale

                    The ActRelationshipType "has subject" is similar to the ParticipationType "subject", Acts that primarily operate on physical subjects use the Participation, those Acts that primarily operate on other Acts (other information) use the ActRelationship.

                       Discussion: This includes the concept of a  required act for a service or financial instrument such as an insurance plan or policy. In such cases, the trigger is the occurrence of a specific condition such as coverage limits being exceeded.

                       UsageNotes: A usage relationship only makes sense if the target act is authored and occurs independently of the source act.  Otherwise a simpler relationship such as COMP would be appropriate.

                    
                       Rationale: There is a need when defining a clinical trial protocol to indicate that the protocol makes use of other protocol or treatment specifications.  This is stronger than the assertion of "references".  References may exist without usage, and in a clinical trial protocol is common to assert both: what other specifications does this trial use and what other specifications does it merely reference.

                       FormalConstraint: Source Act must be an Observation or specialization there-of. Source Act must not have the value attribute specified

                    
                       UsageNote: This relationship allows the result of an observation to be fully expressed as RIM acts as opposed to being embedded in the value attribute.  For example, sending a Document act as the result of an imaging observation, sending a list of Procedures and/or other acts as the result of a medical history observation.

                    The valueNegationInd attribute on the source Act has the same semantics of "negated finding" when it applies to the target of a VALUE ActRelationship as it does to the value attribute.  On the other hand, if the ActRelationship.negationInd is true for a VALUE ActRelationship, that means the specified observation does not have the indicated value but does not imply a negated finding.  Because the semantics are extremely close, it is recommended that Observation.valueNegationInd be used, not ActRelationship.negationInd.

                    
                       OpenIssue: The implications of negationInd on ActRelationship and the valueNegationind on Observation.