Templates

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

Id2.16.840.1.113883.10.20.22.4.14
ref
ccda-
Gültigkeit ab2014‑06‑09
Statusdraft EntwurfVersions-Label2.1
NameProcedureActivityProcedureV2BezeichnungProcedure Activity Procedure (V2)
Beschreibung
en-US 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.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.20.22.4.14
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 11 Transactions und 68 Templates, Benutzt 7 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.3.4.29Transaktionfinal en-US Progress Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.21Transaktionfinal en-US Care Plan (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.28Transaktionfinal en-US Procedure Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.23Transaktionfinal en-US Continuity of Care Document (CCD) (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.30Transaktionfinal en-US Referral Note (V2)2015‑08‑01
1.3.6.1.4.1.32722.77.77.1.4.6Transaktiondraft nl-NL Verzenden gegevens voor behandeling Longregistratie2012‑12‑27 14:12:19
2.16.840.1.113883.3.1937.99.3.4.27Transaktionfinal en-US Operative Note (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.31Transaktionfinal en-US Transfer Summary (V2)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.26Transaktionfinal en-US History and Physical (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.25Transaktionfinal en-US Discharge Summary (V3)2015‑08‑01
2.16.840.1.113883.3.1937.99.3.4.22Transaktionfinal en-US 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
Benutzt als 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
BeziehungSpezialisierung: Template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
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Version: Template 2.16.840.1.113883.10.20.22.4.14 Procedure Activity Procedure (2013‑01‑31)
ref
ccda-
ItemDTKardKonfBeschreibungLabel
cda:procedure
ProcdotsreV2
@classCode
cs1 … 1FPROCCONFdots7652
 en-US 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
 en-US 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 … 1Men-US C-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.14
cda:templateId
II1 … 1Men-US SHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that itCONFdots7654
@root
uid1 … 1F2.16.840.1.113883.10.20.22.4.14CONFdots0521
 en-US 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
 en-US SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506).
cda:id
II1 … *en-US SHALL contain at least one [1..*] id (CONF:1098-7655).CONFdots7655
cda:code
1 … 1en-US SHALL contain exactly one [1..1] code (CONF:1098-7656).CONFdots7656
cda:originalText
0 … 1Ren-US This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203).CONFdots9203
cda:reference
0 … 1Ren-US The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19204).CONFdots9204
@value
0 … 1 en-US 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, '#') 
 MeldungThis 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 … 1Ren-US SHALL contain exactly one [1..1] statusCode (CONF:1098-7661).CONFdots7661
cda:effectiveTime
0 … 1Ren-US SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662).CONFdots7662
cda:priorityCode
0 … 1en-US MAY 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
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
cda:methodCode
0 … 1en-US MAY contain zero or one [0..1] methodCode (CONF:1098-7670).CONFdots7670
 Constrainten-US methodCode *SHALL NOT* conflict with the method inherent in Procedure / code.
cda:targetSiteCode
0 … *Ren-US

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
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (DYNAMIC)
cda:specimen
0 … *en-US MAY contain zero or more [0..*] specimen (CONF:1098-7697).CONFdots7697
 Constrainten-US This specimen is for representing specimens obtained from a procedure.
cda:specimenRole
1 … 1Men-US The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:1098-7704).CONFdots7704
cda:id
II0 … *Ren-US This specimenRole SHOULD contain zero or more [0..*] id (CONF:1098-7716).CONFdots7716
 Constrainten-US 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
cda:performer
0 … *Ren-US SHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that itCONFdots7718
cda:assignedEntity
1 … 1Men-US SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720).CONFdots7720
cda:id
II1 … *en-US This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722).CONFdots7722
cda:addr
AD1 … *en-US This assignedEntity SHALL contain at least one [1..*] addr (CONF:1098-7731).CONFdots7731
cda:telecom
TEL1 … *en-US This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1098-7732).CONFdots7732
cda:representedOrganization
0 … 1Ren-US This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-7733).CONFdots7733
cda:id
II0 … *Ren-US The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-7734).CONFdots7734
cda:name
0 … *en-US The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-7735).CONFdots7735
cda:telecom
TEL1 … 1en-US The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-7737).CONFdots7737
cda:addr
AD1 … 1en-US The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-7736).CONFdots7736
cda:author
0 … *en-US SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32479).


Beinhaltet 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)
CONFdots2479
cda:participant
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.37 Product Instance (2015‑08‑13)CONFdots7751
@typeCode
cs1 … 1FDEVCONFdots7752
 en-US 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 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2015‑08‑13)CONFdots7765
@typeCode
cs1 … 1FLOCCONFdots7766
 en-US 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 … *en-US MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) such that itCONFdots7768
@typeCode
cs1 … 1FCOMPCONFdots7769
 en-US 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
 en-US SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009).
cda:encounter
1 … 1Men-US SHALL contain exactly one [1..1] encounter (CONF:1098-7770).CONFdots7770
@classCode
cs1 … 1FENCCONFdots7771
 en-US 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
 en-US 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 … 1en-US This encounter SHALL contain exactly one [1..1] id (CONF:1098-7773).CONFdots7773
 Constrainten-US Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.
cda:entryRelationship
0 … 1Beinhaltet 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)CONFdots7775
@typeCode
cs1 … 1FSUBJCONFdots7776
 en-US 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
 en-US SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-7777).
cda:entryRelationship
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09)CONFdots7779
@typeCode
cs1 … 1FRSONCONFdots7780
 en-US 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 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.16 Medication Activity (V2) (2014‑06‑09)CONFdots7886
@typeCode
cs1 … 1FCOMPCONFdots7887
 en-US 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 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)CONFdots2473
@typeCode
cs1 … 1FCOMPCONFdots2474
 en-US SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32474).

Template Procedure Activity Procedure 2013‑01‑31

Id2.16.840.1.113883.10.20.22.4.14
ref
ccda-
Gültigkeit ab2013‑01‑31
Statusdraft EntwurfVersions-Label1.1
NameProcedureActivityProcedureBezeichnungProcedure Activity Procedure
Beschreibung
en-US 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.
KontextElternknoten des Template-Element mit Id 2.16.840.1.113883.10.20.22.4.14
KlassifikationCDA Entry Level Template
Offen/GeschlossenOffen (auch andere als die definierten Elemente sind erlaubt)
Benutzt von / Benutzt
Benutzt von 7 Transactions und 32 Templates, Benutzt 5 Templates
Benutzt von als NameVersion
2.16.840.1.113883.3.1937.99.3.4.4Transaktionfinal en-US Progress Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.3Transaktionfinal en-US Discharge Summary (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.5Transaktionfinal en-US Procedure Note (US Realm – Release 1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.2Transaktionfinal en-US Consultation Notes (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.1Transaktionfinal en-US Continuity of Care Document (CCD) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.6Transaktionfinal en-US Operative Note (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.3.4.7Transaktionfinal en-US History and Physical (H and P) (Release 1.1)2013‑01‑31
2.16.840.1.113883.3.1937.99.61.26.10.52linkdraft Procedure Activity Procedure (1.1)2019‑03‑06 11:55:46
2.16.840.1.113883.3.1937.99.61.41.10.4linkdraft Discharge Summary (1.1)2018‑02‑19 15:30:38
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
2.16.840.1.113883.10.20.22.4.30linkdraft 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
Benutzt als 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
ItemDTKardKonfBeschreibungLabel
cda:procedure
Procdotsdure
@classCode
cs1 … 1FPROCconf‑7652
@moodCode
cs1 … 1Rconf‑7653
 CONF
Der Wert von @moodCode muss gewählt werden aus dem Value Set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
cda:templateId
II1 … 1Men-US SHALL 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 … *Ren-US SHALL contain at least one [1..*] id (CONF:7655).conf‑7655
cda:code
1 … 1Ren-US SHALL contain exactly one [1..1] code (CONF:7656).conf‑7656
cda:originalText
0 … 1Ren-US This code SHOULD contain zero or one [0..1] originalText (CONF:19203).confdots9203
cda:reference
0 … 1Ren-US The 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, '#') 
 MeldungThis 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 … 1Ren-US SHALL 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
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.11.20.9.22 ProcedureAct statusCode (DYNAMIC)
cda:effectiveTime
0 … 1Ren-US SHOULD contain zero or one [0..1] effectiveTime (CONF:7662).conf‑7662
cda:priorityCode
0 … 1en-US MAY 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
Der Wert von @code muss gewählt werden aus dem Value Set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
cda:methodCode
CE0 … 1en-US MAY 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 … *Ren-US SHOULD contain zero or more [0..*] targetSiteCode (CONF:7683).conf‑7683
@code
1 … 1Rconfdots6082
cda:specimen
0 … *en-US MAY contain zero or more [0..*] specimen (CONF:7697).

This specimen is for representing specimens obtained from a procedure.
conf‑7697
cda:specimenRole
1 … 1Men-US The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:7704).conf‑7704
cda:id
II0 … *Ren-US This 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 … *Ren-US SHOULD contain zero or more [0..*] performer (CONF:7718) such that itconf‑7718
cda:assignedEntity
1 … 1Men-US SHALL contain exactly one [1..1] assignedEntity (CONF:7720).conf‑7720
cda:id
II1 … *Ren-US This assignedEntity SHALL contain at least one [1..*] id (CONF:7722).conf‑7722
cda:addr
AD1 … *Ren-US This assignedEntity SHALL contain at least one [1..*] addr (CONF:7731).conf‑7731
cda:telecom
TEL1 … *Ren-US This assignedEntity SHALL contain at least one [1..*] telecom (CONF:7732).conf‑7732
cda:representedOrganization
0 … 1Ren-US This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:7733).conf‑7733
cda:id
II0 … *Ren-US The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:7734).conf‑7734
cda:name
0 … *en-US The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:7735).conf‑7735
cda:telecom
TEL1 … 1Ren-US The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:7737).conf‑7737
cda:addr
AD1 … 1Ren-US The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:7736).conf‑7736
cda:participant
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.37 Product Instance (2013‑01‑31)conf‑7751
@typeCode
cs1 … 1FDEVconf‑7752
cda:participant
0 … *Beinhaltet 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 … *en-US MAY contain zero or more [0..*] entryRelationship (CONF:7768) such that itconf‑7768
@typeCode
cs1 … 1FCOMPconf‑7769
@inversionInd
bl1 … 1Ftrueconf‑8009
cda:encounter
1 … 1Men-US SHALL contain exactly one [1..1] encounter (CONF:7770).conf‑7770
@classCode
cs1 … 1FENCconf‑7771
@moodCode
cs1 … 1FEVNconf‑7772
cda:id
II1 … 1Ren-US This 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 … 1Beinhaltet 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 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.19 Indication (2013‑01‑31)conf‑7779
@typeCode
cs1 … 1FRSONconf‑7780
cda:entryRelationship
0 … *Beinhaltet 2.16.840.1.113883.10.20.22.4.16 Medication Activity (2013‑01‑31)conf‑7886
@typeCode
cs1 … 1FCOMPconf‑7887