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

Id2.16.840.1.113883.10.20.22.4.14
ref
ccda-
Effective Date2014‑06‑09
Statusdraft DraftVersion Label2.1
NameProcedureActivityProcedureV2Display NameProcedure Activity Procedure (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 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. This template can be used with a contained Product Instance template to represent a device in or on a patient. In this case, targetSiteCode is used to record the location of the device in or on the patient's body. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity (V2) template.
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 11 transactions and 68 templates, Uses 7 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.29Transactionfinal Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transactionfinal Care Plan (V2)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
1.3.6.1.4.1.32722.77.77.1.4.6Transactiondraft nl-NL Verzenden gegevens voor behandeling Longregistratie2012‑12‑27 14:12:19
2.16.840.1.113883.3.1937.99.3.4.27Transactionfinal Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transactionfinal Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transactionfinal History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transactionfinal Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transactionfinal Consultation Note (V3)2015‑08‑01
1.2.276.0.76.3.1.135.8.10.4Containmentdraft Medical Equipment Section (V2) (2.1)2015‑12‑02 12:50:20
1.2.276.0.76.3.1.135.8.10.99linkcancelled 16: eRezept (duplicate)2018‑11‑02 09:37:45
1.2.276.0.76.10.3117linkdraft Medications Section (entries optional) (V2) (06) (2.1)2016‑09‑06 17:26:48
1.3.6.1.4.1.32722.77.77.1.10.7linkdraft Radiotherapeutische Longregistratie voor aanvang behandeling2013‑02‑20
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
2.16.840.1.113883.3.1937.99.61.17.10.2linkdraft SHN StructuredBody2015‑05‑09 11:18:02
2.16.840.1.113883.3.1937.99.61.17.10.3linkdraft SHN component2015‑05‑09 11:28:46
2.16.840.1.113883.3.1937.99.61.18.10.6linkdraft Выписной эпикриз2015‑06‑06 14:32:25
2.16.840.1.113883.3.1937.99.61.20.10.9linkdraft Medications Section (entries required) (V2) (2.1)2015‑11‑03 08:58:06
2.16.840.1.113883.3.1937.99.61.26.10.54linkrejected Procedure Activity Procedure (V2) (2.1)2019‑03‑06 15:52:43
2.16.840.1.113883.3.1937.99.61.26.10.55linkdraft Allergy - Intolerance Observation (V2) (2.1)2019‑03‑08 04:36:16
2.16.840.1.113883.3.1937.99.61.26.10.61linkdraft Allergy Concern Act (V3) (2.1)2019‑03‑09 13:34:13
2.16.840.1.113883.3.1937.99.61.26.10.62linkrejected Allergies and Intolerances Section (entries optional) (V3) (2.1)2019‑03‑09 13:37:11
2.16.840.1.113883.3.1937.99.61.26.10.112linkrejected Adverse Events Section (entries optional) (V3) (2.1)2019‑03‑25 06:01:02
2.16.840.1.113883.3.1937.99.61.26.10.114linkrejected Medication Activity (V2) (2.1)2019‑03‑31 19:39:09
2.16.840.1.113883.3.1937.99.61.28.10.3linkdraft CDA de Consulta (1)2017‑04‑22 23:20:01
2.16.840.1.113883.3.1937.99.61.30.10.54linkcancelled Health Concern Act (harmonized) (0.1)2020‑10‑08 10:55:41
2.16.840.1.113883.3.1937.99.61.30.10.58linkdraft _Allergy - Intolerance Observation (harmonization)) (wip)2020‑10‑16 15:17:11
2.16.840.1.113883.3.1937.99.61.30.10.60linkdraft _Immunization (harmonized) (IAT)2021‑07‑06 09:55:32
2.16.840.1.113883.3.1937.99.61.67.10.24linkcancelled XeH Alert Act2021‑04‑20 10:00:04
2.16.840.1.113883.3.1937.99.61.67.10.25linkcancelled XeH Risk Concern Act2021‑04‑20 10:06:56
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
2.16.840.1.113883.10.20.22.1.7linkdraft Operative 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
2.16.840.1.113883.10.20.22.2.1linkdraft Medications Section (entries optional) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.1.1linkdraft Medications Section (entries required) (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.2linkdraft Immunizations Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.2.1linkdraft Immunizations Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6linkdraft Allergies and Intolerances Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.6.1linkdraft Allergies and Intolerances Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.7Containmentdraft Procedures Section (entries optional)2012‑01‑12
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
2.16.840.1.113883.10.20.22.2.11linkdraft Discharge Medications Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.11.1linkdraft Discharge Medications Section (entries required) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.23linkdraft Medical Equipment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.38linkdraft Medications Administered Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.44linkdraft Admission Medications Section (entries optional) (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.58linkdraft Health Concerns Section (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.78linkdraft BC CDA Medication Activity (V2) (2.1)2019‑03‑15 14:29:33
2.16.840.1.113883.10.20.22.2.101linkdraft BC CDA Referral Note (V2) (2.1)2019‑04‑06 02:03:17
2.16.840.1.113883.10.20.22.4.7linkdraft Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.9linkdraft Reaction Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.12linkdraft Procedure Activity Act (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.13linkdraft Procedure Activity Observation (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.14linkdraft Procedure Activity Procedure (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.30linkdraft Allergy Concern Act (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.35linkcancelled Discharge Medication (V3) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.35linkdraft Discharge Medication (V3) (2.1)2016‑03‑01
2.16.840.1.113883.10.20.22.4.36linkdraft Admission Medication (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.4.52linkdraft Immunization Activity (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.131Containmentdraft Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.132linkdraft Health Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.135Containmentdraft Medical Equipment Organizer (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.136linkdraft Risk Concern Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.4.146Containmentdraft Planned Intervention Act (V2) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.24.3.90linkdraft Substance or Device Allergy - Intolerance Observation (V2) (2.1)2014‑06‑09
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
2.16.840.1.113883.10.20.22.4.37Containmentdraft Product Instance (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.4.119Containmentdraft Author Participation (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
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ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.14 Procedure Activity Procedure (2013‑01‑31)
ref
ccda-
ItemDTCardConfDescriptionLabel
cda:procedure
ProcdotsreV2
@classCode
cs1 … 1FPROCCONFdots7652
 SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7652).
@moodCode
cs1 … 1FEVNCONFdots7653
 SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7653).
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.14
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that itCONFdots7654
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.14CONFdots0521
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14" (CONF:1098-10521).
@extension
st1 … 1F2014-06-09CONFdots2506
 SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506).
cda:id
II1 … *SHALL contain at least one [1..*] id (CONF:1098-7655).CONFdots7655
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:1098-7656).CONFdots7656
cda:originalText
0 … 1RThis code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203).CONFdots9203
cda:reference
0 … 1RThe originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19204).CONFdots9204
@value
0 … 1 The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19205).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 (CONF:1098-7661).CONFdots7661
cda:effectiveTime
0 … 1RSHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662).CONFdots7662
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:1098-7668).CONFdots7668
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
cda:methodCode
0 … 1MAY contain zero or one [0..1] methodCode (CONF:1098-7670).CONFdots7670
 ConstraintmethodCode *SHALL NOT* conflict with the method inherent in Procedure / code.
cda:targetSiteCode
0 … *R

In the case of an implanted medical device, targetSiteCode is used to record the location of the device, in or on the patient's body.

SHOULD 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:1098-7683)


CONFdots7683
 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:specimen
0 … *MAY contain zero or more [0..*] specimen (CONF:1098-7697).CONFdots7697
 ConstraintThis specimen is for representing specimens obtained from a procedure.
cda:specimenRole
1 … 1MThe specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:1098-7704).CONFdots7704
cda:id
II0 … *RThis specimenRole SHOULD contain zero or more [0..*] id (CONF:1098-7716).CONFdots7716
 ConstraintIf 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
cda:performer
0 … *RSHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that itCONFdots7718
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720).CONFdots7720
cda:id
II1 … *This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722).CONFdots7722
cda:addr
AD1 … *This assignedEntity SHALL contain at least one [1..*] addr (CONF:1098-7731).CONFdots7731
cda:telecom
TEL1 … *This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1098-7732).CONFdots7732
cda:representedOrganization
0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-7733).CONFdots7733
cda:id
II0 … *RThe representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-7734).CONFdots7734
cda:name
0 … *The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-7735).CONFdots7735
cda:telecom
TEL1 … 1The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-7737).CONFdots7737
cda:addr
AD1 … 1The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-7736).CONFdots7736
cda:author
0 … *SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32479).


Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)		CONFdots2479
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.37 Product Instance (2015‑08‑13)CONFdots7751
@typeCode
cs1 … 1FDEVCONFdots7752
 SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7752).
cda:participant
0 … *Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2015‑08‑13)CONFdots7765
@typeCode
cs1 … 1FLOCCONFdots7766
 SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7766).
cda:entryRelationship
0 … *MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) such that itCONFdots7768
@typeCode
cs1 … 1FCOMPCONFdots7769
 SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7769).
@inversionInd
bl1 … 1FtrueCONFdots8009
 SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009).
cda:encounter
1 … 1MSHALL contain exactly one [1..1] encounter (CONF:1098-7770).CONFdots7770
@classCode
cs1 … 1FENCCONFdots7771
 This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7771).
@moodCode
cs1 … 1FEVNCONFdots7772
 This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7772).
cda:id
II1 … 1This encounter SHALL contain exactly one [1..1] id (CONF:1098-7773).CONFdots7773
 ConstraintSet the 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)CONFdots7775
@typeCode
cs1 … 1FSUBJCONFdots7776
 SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7776).
@inversionInd
bl1 … 1FtrueCONFdots7777
 SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-7777).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09)CONFdots7779
@typeCode
cs1 … 1FRSONCONFdots7780
 SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7780).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (V2) (2014‑06‑09)CONFdots7886
@typeCode
cs1 … 1FCOMPCONFdots7887
 SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7887).
cda:entryRelationship
0 … *Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)CONFdots2473
@typeCode
cs1 … 1FCOMPCONFdots2474
 SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32474).