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Template Procedure Note 2013‑01‑31

Id2.16.840.1.113883.10.20.22.1.6Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameProcedureNoteDisplay NameProcedure Note
Description
Procedure Note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are documents that are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient’s tolerance of the procedure. The document should be sufficiently detailed to justify the procedure, describe the course of the procedure, and provide continuity of care.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 28 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentdraft History of Present Illness Section (1.1)2013‑01‑31
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.18.2.9Containmentdraft Procedure Estimated Blood Loss Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.18.2.12Containmentdraft Procedure Disposition Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Care Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.12Containmentdraft Reason for Visit Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.13Containmentdraft Chief Complaint and Reason for Visit Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.20Containmentdraft History of Past Illness Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.27Containmentdraft Procedure Description Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.28Containmentdraft Procedure Findings Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.29Containmentdraft Procedure Indications Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.30Containmentdraft Planned Procedure Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.31Containmentdraft Procedure Specimens Taken Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.36Containmentdraft Postprocedure Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.37Containmentdraft Complications Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.38Containmentdraft Medications Administered Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.39Containmentdraft Medical (General) History Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.40Containmentdraft Procedure Implants Section (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent.ProcdotsNote
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:8496) such that itconf‑8496
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.6confdots0050
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:17182).confdots7182
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:8504) such that itconf‑8504
@typeCode
cs1 … 1FINDconf‑8505
cda:functionCode
CE1 … 1MSHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: participationFunction 2.16.840.1.113883.5.88 STATIC) (CONF:8506).conf‑8506
@code
CONF1 … 1FPCP
@codeSystem
1 … 1F2.16.840.1.113883.5.88
cda:associatedEntity
1 … 1MSHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8507).conf‑8507
@classCode
cs1 … 1FPROVconf‑8507
cda:associatedPerson
1 … 1This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:8508).conf‑8508
cda:documentationOf
1 … *MSHALL contain at least one [1..*] documentationOf (CONF:8510) such that it

Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF).		conf‑8510
cda:serviceEvent
1 … 1MSHALL contain exactly one [1..1] serviceEvent (CONF:10061).

The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC.		confdots0061
cda:code
1 … The value of Clinical Document/documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMICconfdots0061
 CONF
@codeSystem shall be "2.16.840.1.113883.6.104"
or
@codeSystem shall be "2.16.840.1.113883.6.12"
or
@codeSystem shall be "2.16.840.1.113883.6.96"
cda:effectiveTime
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:10062).

The serviceEvent/effectiveTime SHALL be present with effectiveTime/low

If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high

When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)		confdots0062
 Schematron assertrolered error 
 testnot(.//@value[not(parent::cda:width)][string-length()<8]) 
 MessageThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) 
cda:low
1 … 1RThis effectiveTime SHALL contain exactly one [1..1] low (CONF:26449).confdots6449
Choice1 … 1
If a width element is not present, the serviceEvent SHALL include effectiveTime/high
Elements to choose from:
  • cda:width
  • cda:high
cda:width
confdots0062
cda:high
confdots0062
cda:performer
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] performer (CONF:8520).conf‑8520
@typeCode
cs1 … 1FPPRFconf‑8521
cda:assignedEntity
1 … 1MThis performer SHALL contain exactly one [1..1] assignedEntity (CONF:14911).confdots4911
cda:code
CE0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] code (CONF:14912).confdots4912
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:9588).

A Procedure Note can have either a structuredBody or a nonXMLBody

A Procedure Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.6), coded entries are optional.

If structuredBody, the component/structuredBody SHALL conform to the section constraints below

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.

Each section SHALL have a title and the title SHALL NOT be empty

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present

SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section		conf‑9588
Choice1 … 1
An Procedure Note can have either a structuredBody or a nonXMLBody
Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
cda:nonXMLBody
conf‑9588
cda:structuredBody
conf‑9588
 Schematron assertrolered error 
 test//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'] or (//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] and //cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) 
 MessageSHALL include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan Section (2.16.840.1.113883.10.20.22.2.10). 
 Schematron assertrolered error 
 testnot(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9']) or ( not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8']) and not(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10']) ) 
 MessageSHALL NOT include an Assessment and Plan Section (2.16.840.1.113883.10.20.22.2.9) when an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Care Section (2.16.840.1.113883.10.20.22.2.10) are present 
 Schematron assertrolered error 
 testnot(.//cda:section[not(cda:title)]) and not(.//cda:section/cda:title[string-length()=0]) 
 MessageEach section SHALL have a title and the title SHALL NOT be empty 
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2013‑01‑31)conf‑9645
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)conf‑9647
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (2013‑01‑31)conf‑9649
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (2013‑01‑31)conf‑9802
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (2013‑01‑31)conf‑9805
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (2013‑01‑31)conf‑9807
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (2013‑01‑31)conf‑9809
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (2013‑01‑31)conf‑9811
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2013‑01‑31)conf‑9813
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2013‑01‑31)conf‑9815
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (2013‑01‑31)conf‑9817
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (2013‑01‑31)conf‑9819
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2013‑01‑31)conf‑9821
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.39 Medical (General) History Section (2013‑01‑31)conf‑9823
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (2013‑01‑31)conf‑9825
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.38 Medications Administered Section (2013‑01‑31)conf‑9827
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (2013‑01‑31)conf‑9829
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (2013‑01‑31)conf‑9831
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (2013‑01‑31)conf‑9833
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (2013‑01‑31)conf‑9835
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (2013‑01‑31)conf‑9837
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (2013‑01‑31)conf‑9839
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (2013‑01‑31)conf‑9841
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (2013‑01‑31)conf‑9843
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2013‑01‑31)conf‑9845
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2013‑01‑31)conf‑9847
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (2013‑01‑31)conf‑9849
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.36 Postprocedure Diagnosis Section (2013‑01‑31)conf‑9850
cda:componentOf
0 … 1RSHOULD contain zero or one [0..1] componentOf/encompassingEncounter (CONF:8499).conf‑8499
cda:encompassingEncounter
1 … 1Mconf‑8499
cda:code
1 … 1The componentOf/encompassingEncounter, if present, SHALL contain exactly one [1..1] code (CONF:8501).conf‑8501
cda:encounterParticipant
0 … 1The componentOf/encompassingEncounter, if present, MAY contain zero or one [0..1] encounterParticipant (CONF:8502) such that itconf‑8502
@typeCode
cs1 … 1FREFconf‑8503
cda:location
1 … *MThe componentOf/encompassingEncounter, if present, SHALL contain at least one [1..*] location/healthCareFacility/id (CONF:8500).conf‑8500
cda:healthCareFacility
1 … 1Mconf‑8500
cda:id
II1 … 1conf‑8500