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Template Procedure Activity Observation (V2) 2014‑06‑09

Id2.16.840.1.113883.10.20.22.4.13Effective Date2014‑06‑09
Statusdraft DraftVersion Label2.1
NameProcedureActivityObservationV2Display NameProcedure Activity Observation (V2)
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 template 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 9 transactions and 17 templates, Uses 6 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transactionfinal Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transactionfinal Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transactionfinal Referral Note (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.51.60.2.4linkpending BC CDA ClinicalDocumentDischargeSummary (V3) (2.1)2019‑03‑19 14:15:51
2.16.840.1.113883.3.1937.99.61.8.10.3.4Containmentdraft Procedures Section (entries required)2014‑02‑04 13:13:02
2.16.840.1.113883.10.20.21.2.3linkdraft Interventions Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.2linkdraft Continuity of Care Document (CCD) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.3linkdraft History and Physical (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.4linkdraft Consultation Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.6linkdraft Procedure Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.13linkdraft Transfer Summary (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.14linkdraft Referral Note (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.1.15linkdraft Care Plan (V2) (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
2.16.840.1.113883.10.20.22.2.7Containmentpending Procedures Section (entries optional) (V2) (2.1)2019‑03‑16 21:12:43
2.16.840.1.113883.10.20.22.2.7.1Containmentdraft Procedures Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.131Containmentdraft Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.146linkdraft Planned Intervention Act (V2) (2.1)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.22.4.9Containmentdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.16Containmentdraft Medication Activity (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.19Containmentdraft Indication (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.20Containmentdraft Instruction (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.32Containmentdraft Service Delivery Location (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
ref
ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.13 Procedure Activity Observation (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:observation
ProcdotsonV2
@classCode
cs1 … 1FOBSCONFdots8282
 SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8282).
@moodCode
cs1 … 1FEVNCONFdots8237
 SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8237).
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.13
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-8238) such that itCONFdots8238
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.13CONFdots0520
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13" (CONF:1098-10520).
@extension
st1 … 1F2014-06-09CONFdots2507
 SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32507).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-8239).CONFdots8239
cda:code
CD1 … 1SHALL contain exactly one [1..1] code (CONF:1098-19197).CONFdots9197
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:1098-19198).CONFdots9198
cda:reference
0 … 1RThe originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19199).CONFdots9199
@value
0 … 1 The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19200).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 … 1RSHALL contain exactly one [1..1] statusCode (CONF:1098-8245).CONFdots8245
cda:effectiveTime
IVL_TS0 … 1RSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-8246).CONFdots8246
cda:priorityCode
0 … 1MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-8247).CONFdots8247
 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:1098-16846).CONFdots6846
@nullFlavor
cs0 … 1 This value MAY contain zero or one [0..1] @nullFlavor (CONF:1098-32778).CONFdots2778
cda:methodCode
0 … 1MAY contain zero or one [0..1] methodCode (CONF:1098-8248).CONFdots8248
 ConstraintmethodCode *SHALL NOT* conflict with the method inherent in Observation / code.
cda:targetSiteCode
0 … *RSHOULD contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-8250).CONFdots8250
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (DYNAMIC)
cda:performer
0 … *RSHOULD contain zero or more [0..*] performer (CONF:1098-8251).CONFdots8251
cda:assignedEntity
1 … 1MThe performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:1098-8252).CONFdots8252
cda:id
II1 … *This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-8253).CONFdots8253
cda:addr
AD1 … *This assignedEntity SHALL contain at least one [1..*] addr (CONF:1098-8254).CONFdots8254
cda:telecom
TEL1 … *This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1098-8255).CONFdots8255
cda:representedOrganization
0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-8256).CONFdots8256
cda:id
II0 … *RThe representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-8257).CONFdots8257
cda:name
0 … *The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-8258).CONFdots8258
cda:telecom
TEL1 … 1The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-8260).CONFdots8260
cda:addr
AD1 … 1The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-8259).CONFdots8259
cda:author
0 … *RSHOULD contain [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32478).
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)		CONFdots2478
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2015‑08‑13)CONFdots8261
@typeCode
cs1 … 1FLOCCONFdots8262
 SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-8262).
cda:entryRelationship
0 … *MAY contain zero or more [0..*] entryRelationship (CONF:1098-8264) such that itCONFdots8264
@typeCode
cs1 … 1FCOMPCONFdots8265
 SHALL contain exactly one [1..1] @typeCode="COMP" Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8265).
@inversionInd
bl1 … 1FtrueCONFdots8266
 SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8266).
cda:encounter
1 … 1MSHALL contain exactly one [1..1] encounter (CONF:1098-8267).CONFdots8267
@classCode
cs1 … 1FENCCONFdots8268
 This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8268).
@moodCode
cs1 … 1FEVNCONFdots8269
 This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-8269).
cda:id
II1 … 1This encounter SHALL contain exactly one [1..1] id (CONF:1098-8270).CONFdots8270
 ConstraintSet encounter/id to the id of an encounter in another section to signify they are the same encounter.
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)CONFdots8272
@typeCode
cs1 … 1FSUBJCONFdots8273
 SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8273).
@inversionInd
bl1 … 1FtrueCONFdots8274
 SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8274).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09)CONFdots8276
@typeCode
cs1 … 1FRSONCONFdots8277
 SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8277).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (V2) (2014‑06‑09)CONFdots8279
@typeCode
cs1 … 1FCOMPCONFdots8280
 SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-8280).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)CONFdots2470
@typeCode
cs1 … 1FCOMPCONFdots2471
 SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32471).