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Template Procedure Activity Observation 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.13Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameProcedureActivityObservationDisplay NameProcedure Activity Observation
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 procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.13
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:observation
Procdotstion
@classCode
cs1 … 1FOBSconf‑8282
@moodCode
cs1 … 1Rconf‑8237
 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:8238) such that itconf‑8238
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.13confdots0520
cda:id
II1 … *RSHALL contain at least one [1..*] id (CONF:8239).conf‑8239
cda:code
CD1 … 1RSHALL contain exactly one [1..1] code (CONF:19197).confdots9197
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:19198).confdots9198
cda:reference
0 … 1RThe originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19199).

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).		confdots9199
@value
0 … 1 confdots9200
 Schematron assertrolered error 
 testnot(@value) or starts-with(@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:8245).conf‑8245
 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
IVL_TS0 … 1RSHOULD contain zero or one [0..1] effectiveTime (CONF:8246).conf‑8246
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:8247).conf‑8247
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
cda:value
1 … 1RSHALL contain exactly one [1..1] value (CONF:16846).confdots6846
cda:methodCode
CE0 … 1MAY contain zero or one [0..1] methodCode (CONF:8248).

methodCode SHALL NOT conflict with the method inherent in Observation / code.		conf‑8248
cda:targetSiteCode
0 … *RSHOULD contain zero or more [0..*] targetSiteCode (CONF:8250).conf‑8250
@code
1 … 1Rconfdots6071
cda:performer
0 … *RSHOULD contain zero or more [0..*] performer (CONF:8251).conf‑8251
cda:assignedEntity
1 … 1MThe performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8252).conf‑8252
cda:id
II1 … *RThis assignedEntity SHALL contain at least one [1..*] id (CONF:8253).conf‑8253
cda:addr
AD1 … *RThis assignedEntity SHALL contain at least one [1..*] addr (CONF:8254).conf‑8254
cda:telecom
TEL1 … *RThis assignedEntity SHALL contain at least one [1..*] telecom (CONF:8255).conf‑8255
cda:representedOrganization
0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8256).conf‑8256
cda:id
II0 … *RThe representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:8257).conf‑8257
cda:name
0 … *The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:8258).conf‑8258
cda:telecom
TEL1 … 1RThe representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8260).conf‑8260
cda:addr
AD1 … 1RThe representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:8259).conf‑8259
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2013‑01‑31)conf‑8261
@typeCode
cs1 … 1FLOCconf‑8262
cda:entryRelationship
0 … *MAY contain zero or more [0..*] entryRelationship (CONF:8264).conf‑8264
@typeCode
cs1 … 1FCOMPconf‑8265
@inversionInd
bl1 … 1Ftrueconf‑8266
cda:encounter
1 … 1MThe entryRelationship, if present, SHALL contain exactly one [1..1] encounter (CONF:8267).conf‑8267
@classCode
cs1 … 1FENCconf‑8268
@moodCode
cs1 … 1FEVNconf‑8269
cda:id
II1 … 1RThis encounter SHALL contain exactly one [1..1] id (CONF:8270).

Set encounter/id to the id of an encounter in another section to signify they are the same encounter.		conf‑8270
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.20 Instructions (2013‑01‑31)conf‑8272
@typeCode
cs1 … 1FSUBJconf‑8273
@inversionInd
bl1 … 1Ftrueconf‑8274
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31)conf‑8276
@typeCode
cs1 … 1FRSONconf‑8277
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (2013‑01‑31)conf‑8279
@typeCode
cs1 … 1FCOMPconf‑8280