Item | DT | Card | Conf | Description | Label |
---|
cda:ClinicalDocument
| | | | A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent. | OperNote |
cda:templateId
| II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:8483) such that it | conf‑8483 |
@root
| uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.1.7 | conf0048 |
cda:code
| | 1 … 1 | | SHALL contain exactly one [1..1] code (CONF:17187). | conf7187 |
cda:documentationOf
| | 1 … * | M | SHALL contain at least one [1..*] documentationOf (CONF:8486).Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF). | conf‑8486 |
cda:serviceEvent
| | 1 … 1 | M | Such documentationOfs SHALL contain exactly one [1..1] serviceEvent (CONF:8493).i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC | conf‑8493 |
cda:code
| CE | 1 … | | i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC | conf‑8493 |
| CONF | @codeSystem shall be "2.16.840.1.113883.6.104" | or | @codeSystem shall be "2.16.840.1.113883.6.12" | or | @codeSystem shall be "2.16.840.1.113883.6.96" |
|
cda:effectiveTime
| IVL_TS | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8494).The serviceEvent/effectiveTime SHALL be present with effectiveTime/low.If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be presentThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | conf‑8494 |
| Schematron assert | role | error | |
| test | not(.//@value[not(parent::cda:width)][string-length()<8]) | |
| Message | The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | |
cda:low
| TS | 1 … 1 | | The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element. The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) | conf‑8494 |
Choice | 1 … 1 | | If a width element is not present, the serviceEvent SHALL include effectiveTime/high Elements to choose from: |
cda:width
| PQR | | | | conf‑8494 |
cda:high
| TS | | | | conf‑8494 |
cda:performer
| | 1 … 1 | M | This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8489) such that it | conf‑8489 |
@typeCode
| cs | 1 … 1 | F | PPRF | conf‑8495 |
cda:assignedEntity
| | 1 … 1 | M | SHALL contain exactly one [1..1] assignedEntity (CONF:10917). | conf0917 |
cda:code
| CE | 1 … 1 | | This assignedEntity SHALL contain exactly one [1..1] code (CONF:8490). | conf‑8490 |
cda:component
| | 1 … 1 | M | SHALL contain exactly one [1..1] component (CONF:9585).An Operative Note can have either a structuredBody or a nonXMLBodyAn Operative Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.7), coded entries are optional If structuredBody, the component/structuredBody SHALL conform to the section constraints below | conf‑9585 |
Choice | 1 … 1 | | An Operative Note can have either a structuredBody or a nonXMLBody Elements to choose from:- cda:nonXMLBody
- cda:structuredBody
|
cda:nonXMLBody
| | | | | conf‑9585 |
cda:structuredBody
| | | | | conf‑9585 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (2013‑01‑31) | conf‑9883 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (2013‑01‑31) | conf‑9885 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.34 Preoperative Diagnosis Section (2013‑01‑31) | conf‑9888 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (2013‑01‑31) | conf‑9890 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (2013‑01‑31) | conf‑9892 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (2013‑01‑31) | conf‑9894 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (2013‑01‑31) | conf‑9896 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (2013‑01‑31) | conf‑9898 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.7.12 Operative Note Fluids Section (2013‑01‑31) | conf‑9900 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.7.14 Operative Note Surgical Procedure Section (2013‑01‑31) | conf‑9902 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31) | conf‑9904 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (2013‑01‑31) | conf‑9906 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (2013‑01‑31) | conf‑9908 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (2013‑01‑31) | conf‑9910 |
cda:component
| | 0 … 1 | | Contains 2.16.840.1.113883.10.20.7.13 Surgical Drains Section (2013‑01‑31) | conf‑9912 |
cda:component
| | 1 … 1 | | Contains 2.16.840.1.113883.10.20.22.2.35 Postoperative Diagnosis Section (2013‑01‑31) | conf‑9913 |