Draft| Description |
This template represents planned alterations of the patient's physical condition. Examples of such procedures are tracheostomy, knee replacement, and craniectomy. The priority of the procedure to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the procedure is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Procedure Template may also indicate the potential insurance coverage for the procedure. |
| Used by 10 transactions and 20 templates, Uses 5 templates | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Operative Note (V3)
ref
ad1bbr-
Version: template 2.16.840.1.113883.10.20.22.4.41 Plan of Care Activity Procedure (2013‑01‑31)
| Item | DT | Card | Conf | Description | Label | |
|---|---|---|---|---|---|---|
| cda:procedure | Plan reV2 | |||||
| @classCode | cs | 1 … 1 | F | PROC | CONF8568 | |
| SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8568). | ||||||
| @moodCode | cs | 1 … 1 | R | SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:1098-8569). | CONF8569 | |
| CONF |
| |||||
| cda:templateId | II | 1 … 1 | M | C-CDA R1.1 templateId root without an extension | CONF2936 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.41 | ||
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:1098-30444) such that it | CONF0444 | |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.41 | CONF0445 | |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.41" (CONF:1098-30445). | ||||||
| @extension | st | 1 … 1 | F | 2014-06-09 | CONF2554 | |
| SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32554). | ||||||
| cda:id | II | 1 … * | SHALL contain at least one [1..*] id (CONF:1098-8571). | CONF8571 | ||
| cda:code | 1 … 1 | SHALL contain exactly one [1..1] code (CONF:1098-31976). | CONF1976 | |||
| cda:statusCode | CS | 1 … 1 | M | SHALL contain exactly one [1..1] statusCode (CONF:1098-30446). | CONF0446 | |
| @code | CONF | 1 … 1 | F | active | ||
| cda:effectiveTime | 0 … 1 | R | SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30447).The effectiveTime in a planned procedure represents the time that the procedure should occur. | CONF0447 | ||
| cda:methodCode | 0 … * | MAY contain zero or more [0..*] methodCode (CONF:1098-31980).In a planned procedure the provider may suggest that a procedure should be performed using a particular method. MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | CONF1980 | |||
| cda:targetSiteCode | 0 … * | MAY 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:1098-31981).The targetSiteCode is used to identify the part of the body of concern for the planned procedure. | CONF1981 | |||
| CONF |
| |||||
| cda:performer | 0 … * | MAY contain zero or more [0..*] performer (CONF:1098-30449).The clinician who is expected to perform the procedure could be identified using procedure/performer. | CONF0449 | |||
| cda:author | 0 … 1 | R | SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31979).The author in a planned procedure represents the clinician who is requesting or planning the procedure. Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) | CONF1979 | ||
| cda:entryRelationship | 0 … * | The following entryRelationship represents the priority that a patient or a provider places on the procedure. Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) | CONF1079 | |||
| @typeCode | cs | 1 … 1 | F | REFR | CONF1080 | |
| SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31080). | ||||||
| cda:entryRelationship | 0 … * | The following entryRelationship represents the indication for the procedure. Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) | CONF1982 | |||
| @typeCode | cs | 1 … 1 | F | RSON | CONF1983 | |
| SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31983). | ||||||
| cda:entryRelationship | 0 … * | The following entryRelationship captures any instructions associated with the planned procedure. Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) | CONF1985 | |||
| @typeCode | cs | 1 … 1 | F | SUBJ | CONF1986 | |
| SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31986). | ||||||
| @inversionInd | bl | 1 … 1 | F | true | CONF1987 | |
| SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-31987). | ||||||
| cda:entryRelationship | 0 … * | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Contains 2.16.840.1.113883.10.20.22.4.129 Planned Coverage (2015‑08‑13) | CONF1990 | |||
| @typeCode | cs | 1 … 1 | F | COMP | CONF1991 | |
| SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:1098-31991). | ||||||