QRDA Category I is not completely clear regarding the application of the negationInd attribute. For most datatypes, it is apparent that the attribute should be applied to the outer element of each corresponding template encompassed within the Patient Data section. But what about templates where the outer element does not support that attribute? Examples:

How should "Encounter Order not done" or "Encounter Performed not done" (which appear to be allowed QDM constructs) be represented? The outer element of the Encounter Order template (2.16.840.1.113883.10.20.24.3.22) is encounter but the Encounter type does not allow a negationInd attribute and none of the components of the template appear suitable to house the attribute. Likewise for the Encounter Performed template.

Similarly, the outer element of the Medication Dispensed template is supply and the Supply type does not allow a negationInd attribute and none of the components of the template appear suitable to house the attribute. Thus it is not clear how "Medication Dispensed not done" would be represented.

How should "Diagnosis Family History not done" (which appears to be an allowed QDM construct) be represented? The outer element of the Diagnosis Family History template (2.16.840.1.113883.10.20.24.3.12) is organizer but the Organizer type does not allow a negationInd attribute. Should the negationInd attribute be placed on the observation element of the contained Family History Observation template? If so, given that the Diagnosis Family History template allows multiple instances ("at least one [1..*]") of the Family History Observation, it would be possible to have a Diagnosis Family History entry that contains a mix of "done" and "not done" observations.