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Template Procedure Note (V3) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.1.6Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameProcedureNoteV3Display NameProcedure Note (V3)
Description
A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient’s tolerance for the procedure. It should be detailed enough 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 29 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
Uses as NameVersion
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1Containmentdraft Chief Complaint Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.4Containmentdraft History of Present Illness Section (2.1)2015‑08‑13
1.3.6.1.4.1.19376.1.5.3.1.3.18Containmentdraft Review of Systems Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.2.10Containmentdraft Physical Exam Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.18.2.9Containmentdraft Procedure Estimated Blood Loss Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.18.2.12Containmentdraft Procedure Disposition Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.1Containmentdraft Medications Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.6Containmentdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.8Containmentdraft Assessment Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.9Containmentdraft Assessment and Plan Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.12Containmentdraft Reason for Visit Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.13Containmentdraft Chief Complaint and Reason for Visit Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.15Containmentdraft Family History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.17Containmentdraft Social History Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.20Containmentdraft Past Medical History (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.27Containmentdraft Procedure Description Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.28Containmentdraft Procedure Findings Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.29Containmentdraft Procedure Indications Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.30Containmentdraft Planned Procedure Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.31Containmentdraft Procedure Specimens Taken Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.36Containmentdraft Postprocedure Diagnosis Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.37Containmentdraft Complications Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.38Containmentdraft Medications Administered Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.39Containmentdraft Medical (General) History Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.40Containmentdraft Procedure Implants Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.5.3Containmentdraft US Realm Date and Time (DT.US.FIELDED) (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.6 Procedure Note (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
CWhen asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALL include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32941).
ProcdotsteV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.6
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-8496) such that itCONFdots8496
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.6CONFdots0050
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.6" (CONF:1198-10050).
@extension
st1 … 1F2015-08-01CONFdots2520
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32520).
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:1198-17182).

The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. 		CONFdots7182
cda:participant
0 … *MAY contain zero or more [0..*] participant (CONF:1198-8504) such that it

The participant element in the Procedure Note header follows the General Header Constraints for participants.		CONFdots8504
@typeCode
cs1 … 1FINDCONFdots8505
 SHALL contain exactly one [1..1] @typeCode="IND" Individual (CodeSystem: participationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8505).
cda:functionCode
CE1 … 1MSHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: participationFunction urn:oid:2.16.840.1.113883.5.88 STATIC) (CONF:1198-8506).CONFdots8506
@code
CONF1 … 1FPCP
@codeSystem
1 … 1F2.16.840.1.113883.5.88
cda:associatedEntity
1 … 1MCONFdots8504
@classCode
cs1 … 1FPROVCONFdots8507
 SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8507).
cda:associatedPerson
1 … 1This associatedEntity SHALL contain exactly one [1..1] associatedPerson (CONF:1198-8508).CONFdots8508
cda:documentationOf
1 … *MSHALL contain at least one [1..*] documentationOf (CONF:1198-8510) such that it

A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.		CONFdots8510
cda:serviceEvent
1 … 1MContains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13)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 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC*.CONFdots0061
 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:performer
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] performer (CONF:1198-8520) such that it

This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.		CONFdots8520
where [@typeCode='PPRF']
@typeCode
cs1 … 1FPPRFCONFdots8521
 SHALL contain exactly one [1..1] @typeCode="PPRF" Primary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8521).
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:1198-14911).CONFdots4911
cda:code
CE0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-14912).CONFdots4912
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:performer
0 … *This serviceEvent MAY contain zero or more [0..*] performer (CONF:1198-32732) such that it

This performer identifies any assistants.		CONFdots2732
where [@typeCode='SPRF']
@typeCode
cs1 … 1FSPRFCONFdots2734
 SHALL contain exactly one [1..1] @typeCode="SPRF" Secondary Performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-32734).
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:1198-32733).CONFdots2733
cda:code
CE0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32735).CONFdots2735
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:authorization
0 … 1MAY contain zero or one [0..1] authorization (CONF:1198-32412).

Authorization represents consent. Consent, if present, shall be represented by authorization/consent.		CONFdots2412
@typeCode
cs1 … 1FAUTHCONFdots2413
 The authorization, if present, SHALL contain exactly one [1..1] @typeCode="AUTH" authorized by (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32413).
cda:consent
1 … 1MThe authorization, if present, SHALL contain exactly one [1..1] consent (CONF:1198-32414).CONFdots2414
@classCode
cs1 … 1FCONSCONFdots2415
 This consent SHALL contain exactly one [1..1] @classCode="CONS" consent (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-32415).
@moodCode
cs1 … 1FEVNCONFdots2416
 This consent SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-32416).
cda:statusCode
CS1 … 1RThis consent SHALL contain exactly one [1..1] statusCode (CONF:1198-32417).CONFdots2417
cda:componentOf
0 … 1RSHOULD contain zero or one [0..1] componentOf (CONF:1198-30871).CONFdots0871
cda:encompassingEncounter
1 … 1MThe componentOf, if present, SHALL contain exactly one [1..1] encompassingEncounter (CONF:1198-30872).CONFdots0872
cda:id
II0 … *RThis encompassingEncounter SHOULD contain zero or more [0..*] id (CONF:1198-32395).CONFdots2395
cda:code
1 … 1This encompassingEncounter SHALL contain exactly one [1..1] code (CONF:1198-30873).CONFdots0873
cda:encounterParticipant
0 … 1This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:1198-30874) such that itCONFdots0874
@typeCode
cs1 … 1FREFCONFdots0875
 SHALL contain exactly one [1..1] @typeCode="REF" Referrer (CONF:1198-30875).
cda:location
1 … *MThis encompassingEncounter SHALL contain at least one [1..*] location (CONF:1198-30876).CONFdots0876
cda:healthCareFacility
1 … 1MSuch locations SHALL contain exactly one [1..1] healthCareFacility (CONF:1198-30877).CONFdots0877
cda:id
II1 … *This healthCareFacility SHALL contain at least one [1..*] id (CONF:1198-30878).CONFdots0878
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:1198-9588).CONFdots9588
cda:structuredBody
1 … 1MThis component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30352).CONFdots0352
 ConstraintThis structuredBody *SHALL NOT* contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (V3) (2015‑08‑01)CONFdots0353
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (2015‑08‑13)CONFdots0355
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (V2) (2014‑06‑09)CONFdots0357
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.36 Postprocedure Diagnosis Section (V3) (2015‑08‑01)CONFdots0359
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (2015‑08‑13)CONFdots0361
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (V2) (2014‑06‑09)CONFdots0363
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)CONFdots0365
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.6 Allergies and Intolerances Section (entries optional) (V3) (2015‑08‑01)CONFdots0367
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (V2) (2014‑06‑09)CONFdots0369
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (2015‑08‑13)CONFdots0371
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (2015‑08‑13)CONFdots0373
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (V3) (2015‑08‑01)CONFdots0375
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.20 Past Medical History (V3) (2015‑08‑01)CONFdots0377
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (2015‑08‑13)CONFdots0379
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.39 Medical (General) History Section (2015‑08‑13)CONFdots0381
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (V2) (2014‑06‑09)CONFdots0383
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.38 Medications Administered Section (V2) (2014‑06‑09)CONFdots0388
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (V3) (2015‑08‑01)CONFdots0390
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (V2) (2014‑06‑09)CONFdots0392
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (2015‑08‑13)CONFdots0394
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (2015‑08‑13)CONFdots0396
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (V3) (2015‑08‑01)CONFdots0398
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (2015‑08‑13)CONFdots0400
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (2015‑08‑13)CONFdots0402
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (V2) (2014‑06‑09)CONFdots0404
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (2015‑08‑13)CONFdots0406
cda:component
0 … 1Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (2015‑08‑13)CONFdots0408
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (V3) (2015‑08‑01)CONFdots0410
 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