Draft| Description |
The procedure entry is used to record procedures that have occured, or which are planned for in the future. In case no procedures are expected to be recorded, a single “NA” nullFlavored procedure entry shall be included in this section. |
| Associated with 3 concepts | ||||||||||||
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| Used by 3 transactions and 27 templates, Uses 1 template | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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epSOS-Patient Summary
eHDSI Patient Summary
Provider Orders Section - coded (2016)| Example |
| <procedure classCode="PROC" moodCode="EVN|INT"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <templateId root="2.16.840.1.113883.10.20.1.29"/> <!-- see text of section --> <templateId root="2.16.840.1.113883.10.20.1.25"/> <!-- see text of section --> <id root="" extension=""/> <code code="" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/> <text> <reference value="#xxx"/> </text> <statusCode code="completed|active|aborted|cancelled"/> <effectiveTime> <low value=""/> <high value=""/> </effectiveTime> <priorityCode code=""/> <approachSiteCode code="" displayName="" codeSystem="" codeSystemName=""/> <targetSiteCode code="" displayName="" codeSystem="" codeSystemName=""/> <author/> <informant/> <entryRelationship typeCode="COMP" inversionInd="true"> <act classCode="ACT" moodCode=""> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/> <id root="" extension=""/> </act> </entryRelationship> <entryRelationship typeCode="RSON"> <act classCode="ACT" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/> <id root="" extension=""/> </act> </entryRelationship></procedure> |
| Patient had an operation on his urinary system in Feb, 2011 |
| <procedure classCode="PROC" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <id nullFlavor="NA"/> <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/> <statusCode code="completed"/> <effectiveTime value="201102"/></procedure> |
| Patient had no procedures to be recorded |
| <procedure classCode="PROC" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <id nullFlavor="NA"/> <code nullFlavor="NA"/> <statusCode code="completed"/> <effectiveTime nullFlavor="NA"/></procedure> |
| Item | DT | Card | Conf | Description | Label | ||||
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| hl7:procedure | R | The templateId indicates that this <procedure> entry conforms to the constraints of this content module. NOTE: When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29, and when in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25. | Entr dure | ||||||
| @classCode | cs | 1 … 1 | F | PROC | |||||
| @moodCode | cs | 1 … 1 | R | ||||||
| CONF |
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| hl7:templateId | II.EPSOS | 1 … 1 | M | Entrdure | |||||
| @root | uid | 1 … 1 | F | 1.3.6.1.4.1.19376.1.5.3.1.4.19 | |||||
| Choice | … 1 | Elements to choose from:
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| hl7:templateId | II.EPSOS | 0 … 1 | C | When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29 | Entrdure | ||||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.29 | |||||
| hl7:templateId | II.EPSOS | 0 … 1 | C | When the procedure is in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25. | Entrdure | ||||
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.1.25 | |||||
| hl7:id | II.EPSOS | 1 … * | R | This required element shall contain an identifier for the procedure. More than one procedure identi-fier may be present. | Entrdure | ||||
| hl7:code | CE.EPSOS | 1 … 1 | R | Procedure Id Code. This element shall be present and should contain a code describing the type of procedure. | R9.2 | ||||
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| @displayName | 0 … 1 | Procedure description | R9.1 | ||||||
| @nullFlavor | cs | 0 … 1 | |||||||
| CONF |
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| Example | <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/> | ||||||||
| hl7:text | ED | 1 … 1 | R | Description of procedures | Entrdure | ||||
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| hl7:reference | TEL | 1 … 1 | M | Entrdure | |||||
| @value | 1 … 1 | R | Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1 | ||||||
| hl7:statusCode | CS | 1 … 1 | R | This element shall be present when used to describe a procedure event. It shall have the value 'completed' for procedures that have been completed and 'active' for procedures that are still in progress. Procedures that were stopped prior to completion shall use the value 'aborted', and procedures that were cancelled before being started shall use the value 'cancelled'. | Entrdure | ||||
| CONF |
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| hl7:effectiveTime | IVL_TS | 1 … 1 | R | IHE-PCC: Procedure Date. This element should be present, and records the time at which the procedure occurred (in EVN mood), or the desired time of the procedure in INT mood. epSOS: Procedure date is required. | R9.3 | ||||
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| hl7:priorityCode | CE.EPSOS | 0 … 1 | R | This element shall be present in INT mood when effectiveTime is not provided, it may be present in 2550 other moods. It indicates the priority of the procedure. | Entrdure | ||||
| CONF |
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| hl7:approachSiteCode | CD.EPSOS | 0 … 1 | R | This element may be present to indicate the procedure approach. | Entrdure | ||||
| @codeSystem | CONF | 0 … 1 | F | 2.16.840.1.113883.5.1052 | |||||
| Example | <code code="RLAQ" codeSystem="2.16.840.1.113883.5.1052" codeSystemName="ActSite" displayName="right lower abd quadrant"/> | ||||||||
| hl7:targetSiteCode | CD.EPSOS | 0 … * | R | This element may be present to indicate the target site of the procedure. | Entrdure | ||||
| Example | <targetSiteCode code="76552005" codeSystem="2.16.840.1.113883.6.96" displayName="skin structure of shoulder"> <qualifier> <name code="272741003" displayName="Laterality"/> <value code="7771000" displayName="Left"/> </qualifier></targetSiteCode> | ||||||||
| hl7:entryRelationship | 0 … * | R | This element may be present to point the encounter in which the procedure was performed, and shall contain an internal reference to the encounter. A <procedure> act may indicate one or more reasons for the procedure. These reasons identify the concern that was the reason for the procedure via an Internal Reference to the concern. The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document. Contains 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 Internal Reference (DYNAMIC) | Entrdure | |||||
| @inversionInd | bl | 0 … 1 | |||||||
