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