Template 2.16.840.1.113883.10.20.22.1.6 Procedure Note

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.6 - ProcedureNote
Id 2.16.840.1.113883.10.20.22.1.6
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑750
Version valid from 2012‑01‑12 status draft
Description Procedure Note is a broad term that encompasses many specific types of non-operative procedures including interventional cardiology, interventional radiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are documents that are differentiated from Operative Notes in that the procedures documented do not involve incision or excision as the primary act.

The Procedure Note is created immediately following a non-operative procedure and records the indications for the procedure and, when applicable, post-procedure diagnosis, pertinent events of the procedure, and the patient’s tolerance of the procedure. The document should be sufficiently detailed to justify the procedure, describe the course of the procedure, and provide continuity of care.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-750
treetree cda:templateId
II 1..1 M conf‑9969
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8496
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.6
treetree cda:code
0..1 R conf‑8497
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.6.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.6.1"
treetree cda:componentOf
_cda:encompassingEncounter
0..1 R conf‑8499
treeblank treetree cda:code
CE 1..1 M conf‑8501
treeblank treetree cda:location
_cda:healthCareFacility
__cda:id
II 1..* M conf‑8500
treeblank treetree cda:encounterParticipant
1..1 conf‑8502
treeblank treeblank treetree @typeCode
1..1 F REF
treetree cda:participant
0..* O conf‑8504
treeblank treetree @typeCode
1..1 F IND
treeblank treetree cda:functionCode
CE 1..1 M conf‑8506
treeblank treeblank treetree @code
1..1 F PCP
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.90
treeblank treeblank treetree @displayName
1..1 F Primary Care Physician
treeblank treetree cda:associatedEntity/@classCode
1..1 M conf‑8507
treeblank treeblank treetree @code
1..1 F PROV
treeblank treeblank treetree @codeSystem
1..1 F 2.16.840.1.113883.5.90
treeblank treeblank treetree @displayName
1..1 F Provider
treeblank treeblank treetree cda:associatedPerson
1..1 M conf‑8508
treetree cda:documentationOf
1..* M Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF). conf‑8510
treeblank treetree cda:serviceEvent
1..1 M conf‑10061
Schematron assert Role red error
Test cda:code[@codeSystem='2.16.840.1.113883.6.96' or @codeSystem='2.16.840.1.113883.6.12' or @codeSystem='2.16.840.1.113883.6.104']
Message
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 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC.
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3) conf‑10062
Schematron assert Role red error
Test cda:low
Message
The serviceEvent/effectiveTime SHALL be present with effectiveTime/low
Schematron assert Role red error
Test count(cda:high | cda:width)=1
Message
If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high
Schematron assert Role red error
Test count(cda:high | cda:width)=1
Message
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 present
treeblank treeblank treetree cda:performer
1..1 M conf‑8520
treeblank treeblank treeblank treetree @typeCode
1..1 F PPRF
treeblank treeblank treeblank treetree cda:code
CE 0..1 R conf‑8522
treeblank treeblank treeblank treeblank treetree @code
0..1
CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.114222.4.11.1066"
treetree cda:component
1..1 M A Procedure Note can have either a structuredBody or a nonXMLBody
A Procedure 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 2.16.840.1.113883.10.20.22.1.6), coded entries are optional.
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑9588
Schematron assert Role red error
Test count(//cda:section[not (cda:title)])=0 and not(//cda:section/cda:title[string-length()=0])
Message
Each section SHALL have a title and the title SHALL NOT be empty
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.
Schematron assert Role red error
Test count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.10'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.9'])=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.8'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.10'])=0)
Message
SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present
Schematron assert Role red error
Test count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'])<=1 and count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.12'])<=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=2 or (count(//cda:templateId[@root='2.16.840.1.113883.10.20.22.2.13'])=1 and count(//cda:templateId[@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1'] | //cda:tempalteId[@root='2.16.840.1.113883.10.20.22.2.12'])=0)
Message
SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section