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Template Procedure Activity Act 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.12Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameProcedureActivityActDisplay NameProcedure Activity Act
Description
The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). This clinical statement represents any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.12
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 5 transactions and 7 templates, Uses 4 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.3Transactionfinal Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transactionfinal Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transactionfinal Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transactionfinal History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1Containmentdraft Procedures Section (entries required) (1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.16Containmentdraft Medication Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.19Containmentdraft Indication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instructions (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.32Containmentdraft Service Delivery Location (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:act
ProcdotsyAct
@classCode
cs1 … 1FACTconf‑8289
@moodCode
cs1 … 1Rconf‑8290
 CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:8291) such that itconf‑8291
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.12confdots0519
cda:id
II1 … *RSHALL contain at least one [1..*] id (CONF:8292).conf‑8292
cda:code
CD1 … 1RSHALL contain exactly one [1..1] code (CONF:8293).conf‑8293
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:19186).confdots9186
cda:reference
0 … 1The originalText, if present, MAY contain zero or one [0..1] reference (CONF:19187).

This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1)		confdots9187
@value
0 … 1 confdots9188
 Schematron assertrolered error 
 testcount(@value, '#') 
 MessageThis reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) 
cda:statusCode
CS1 … 1MSHALL contain exactly one [1..1] statusCode, which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:8298).conf‑8298
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.22 ProcedureAct statusCode (DYNAMIC)
cda:effectiveTime
0 … 1RSHOULD contain zero or one [0..1] effectiveTime (CONF:8299).conf‑8299
cda:priorityCode
0 … 1MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority 2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:8300).conf‑8300
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
cda:performer
0 … *RSHOULD contain zero or more [0..*] performer (CONF:8301).conf‑8301
cda:assignedEntity
1 … 1MThe performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8302).conf‑8302
cda:id
II1 … *RThis assignedEntity SHALL contain at least one [1..*] id (CONF:8303).conf‑8303
cda:addr
AD1 … *RThis assignedEntity SHALL contain at least one [1..*] addr (CONF:8304).conf‑8304
cda:telecom
TEL1 … *RThis assignedEntity SHALL contain at least one [1..*] telecom (CONF:8305).conf‑8305
cda:representedOrganization
0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8306).conf‑8306
cda:id
II0 … *RThe representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:8307).conf‑8307
cda:name
0 … *The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:8308).conf‑8308
cda:telecom
TEL1 … *RThe representedOrganization, if present, SHALL contain at least one [1..*] telecom (CONF:8310).conf‑8310
cda:addr
AD1 … *RThe representedOrganization, if present, SHALL contain at least one [1..*] addr (CONF:8309).conf‑8309
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2013‑01‑31)conf‑8311
@typeCode
cs1 … 1FLOCconf‑8312
cda:entryRelationship
0 … *MAY contain zero or more [0..*] entryRelationship (CONF:8314) such that itconf‑8314
@typeCode
cs1 … 1FCOMPconf‑8315
@inversionInd
bl1 … 1Ftrueconf‑8316
cda:encounter
1 … 1MSHALL contain exactly one [1..1] encounter (CONF:8317).conf‑8317
@classCode
cs1 … 1FENCconf‑8318
@moodCode
cs1 … 1FEVNconf‑8319
cda:id
II1 … 1RThis encounter SHALL contain exactly one [1..1] id (CONF:8320).

Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.		conf‑8320
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.20 Instructions (2013‑01‑31)conf‑8322
@typeCode
cs1 … 1FSUBJconf‑8323
@inversionInd
bl1 … 1Ftrueconf‑8324
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31)conf‑8326
@typeCode
cs1 … 1FRSONconf‑8327
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (2013‑01‑31)conf‑8329
@typeCode
cs1 … 1FCOMPconf‑8330