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Template Procedure Activity Procedure 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.14Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameProcedureActivityProcedureDisplay NameProcedure Activity Procedure
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 whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy.
ContextParent nodes of template element with id 2.16.840.1.113883.10.20.22.4.14
ClassificationCDA Entry Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 7 transactions and 31 templates, Uses 5 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transactionfinal Progress Note (Release 1.1)2013‑01‑31
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
2.16.840.1.113883.3.1937.99.3.4.1Transactionfinal Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.6Transactionfinal Operative Note (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
2.16.840.1.113883.10.20.22.1.2linkdraft 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
2.16.840.1.113883.10.20.22.1.7linkdraft Operative Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.8linkdraft Discharge Summary (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.1.9linkdraft Progress Note (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1linkdraft Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1linkdraft Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies Section (entries required) (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
2.16.840.1.113883.10.20.22.2.11linkdraft Hospital Discharge Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1linkdraft Hospital Discharge Medications Section (entries required) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.38linkdraft Medications Administered Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.44linkdraft Hospital Admission Medications Section (entries optional) (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.12linkdraft Procedure Activity Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.13linkdraft Procedure Activity Observation (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.14linkdraft Procedure Activity Procedure (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.16linkdraft Medication Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Problem Act (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.35linkdraft Discharge Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.36linkdraft Admission Medication (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (1.1)2013‑01‑31
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (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
2.16.840.1.113883.10.20.22.4.37Containmentdraft Product Instance (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:procedure
Procdotsdure
@classCode
cs1 … 1FPROCconf‑7652
@moodCode
cs1 … 1Rconf‑7653
 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:7654) such that itconf‑7654
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.14confdots0521
cda:id
II1 … *RSHALL contain at least one [1..*] id (CONF:7655).conf‑7655
cda:code
1 … 1RSHALL contain exactly one [1..1] code (CONF:7656).conf‑7656
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:19203).confdots9203
cda:reference
0 … 1RThe originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19204).

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).		confdots9204
@value
0 … 1 confdots9205
 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, which SHALL be selected from ValueSet ProcedureAct statusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:7661).conf‑7661
 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:7662).conf‑7662
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:7668).conf‑7668
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
cda:methodCode
CE0 … 1MAY contain zero or one [0..1] methodCode (CONF:7670).

methodCode SHALL NOT conflict with the method inherent in Procedure / code.		conf‑7670
cda:targetSiteCode
0 … *RSHOULD contain zero or more [0..*] targetSiteCode (CONF:7683).conf‑7683
@code
1 … 1Rconfdots6082
cda:specimen
0 … *MAY contain zero or more [0..*] specimen (CONF:7697).

This specimen is for representing specimens obtained from a procedure.		conf‑7697
cda:specimenRole
1 … 1MThe specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:7704).conf‑7704
cda:id
II0 … *RThis specimenRole SHOULD contain zero or more [0..*] id (CONF:7716).

If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id		conf‑7716
cda:performer
0 … *RSHOULD contain zero or more [0..*] performer (CONF:7718) such that itconf‑7718
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:7720).conf‑7720
cda:id
II1 … *RThis assignedEntity SHALL contain at least one [1..*] id (CONF:7722).conf‑7722
cda:addr
AD1 … *RThis assignedEntity SHALL contain at least one [1..*] addr (CONF:7731).conf‑7731
cda:telecom
TEL1 … *RThis assignedEntity SHALL contain at least one [1..*] telecom (CONF:7732).conf‑7732
cda:representedOrganization
0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:7733).conf‑7733
cda:id
II0 … *RThe representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:7734).conf‑7734
cda:name
0 … *The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:7735).conf‑7735
cda:telecom
TEL1 … 1RThe representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:7737).conf‑7737
cda:addr
AD1 … 1RThe representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:7736).conf‑7736
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.37 Product Instance (2013‑01‑31)conf‑7751
@typeCode
cs1 … 1FDEVconf‑7752
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2013‑01‑31)conf‑7765
@typeCode
cs1 … 1FLOCconf‑7766
cda:entryRelationship
0 … *MAY contain zero or more [0..*] entryRelationship (CONF:7768) such that itconf‑7768
@typeCode
cs1 … 1FCOMPconf‑7769
@inversionInd
bl1 … 1Ftrueconf‑8009
cda:encounter
1 … 1MSHALL contain exactly one [1..1] encounter (CONF:7770).conf‑7770
@classCode
cs1 … 1FENCconf‑7771
@moodCode
cs1 … 1FEVNconf‑7772
cda:id
II1 … 1RThis encounter SHALL contain exactly one [1..1] id (CONF:7773).

Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.		conf‑7773
cda:entryRelationship
0 … 1Contains 2.16.840.1.113883.10.20.22.4.20 Instructions (2013‑01‑31)conf‑7775
@typeCode
cs1 … 1FSUBJconf‑7776
@inversionInd
bl1 … 1Ftrueconf‑7777
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31)conf‑7779
@typeCode
cs1 … 1FRSONconf‑7780
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (2013‑01‑31)conf‑7886
@typeCode
cs1 … 1FCOMPconf‑7887