Back To Index  <<  Back To Templates

pending Template  Procedure Note

Template 2.16.840.1.113883.10.20.22.1.6 - ProcedureNote
Id 2.16.840.1.113883.10.20.22.1.6
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 28 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.2.8 Containment AssessmentSection DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
2.16.840.1.113883.10.20.22.2.9 Containment AssessmentandPlanSection DYNAMIC
2.16.840.1.113883.10.20.22.2.37 Containment ComplicationsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.27 Containment ProcedureDescriptionSection DYNAMIC
2.16.840.1.113883.10.20.22.2.29 Containment ProcedureIndicationsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.6 Containment AllergiesSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.25 Containment AnesthesiaSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Containment ChiefComplaintSection DYNAMIC
2.16.840.1.113883.10.20.22.2.13 Containment ChiefComplaintandReasonforVisitSection DYNAMIC
2.16.840.1.113883.10.20.22.2.15 Containment FamilyHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.20 Containment HistoryofPastIllnessSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.4 Containment HistoryofPresentIllnessSection DYNAMIC
2.16.840.1.113883.10.20.22.2.39 Containment MedicalGeneralHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.1 Containment MedicationsSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.38 Containment MedicationsAdministeredSection DYNAMIC
2.16.840.1.113883.10.20.2.10 Containment PhysicalExamSection DYNAMIC
2.16.840.1.113883.10.20.22.2.30 Containment PlannedProcedureSection DYNAMIC
2.16.840.1.113883.10.20.18.2.12 Containment ProcedureDispositionSection DYNAMIC
2.16.840.1.113883.10.20.18.2.9 Containment ProcedureEstimatedBloodLossSection DYNAMIC
2.16.840.1.113883.10.20.22.2.28 Containment ProcedureFindingsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.40 Containment ProcedureImplantsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.31 Containment ProcedureSpecimensTakenSection DYNAMIC
2.16.840.1.113883.10.20.22.2.7 Containment ProceduresSectionentriesoptional DYNAMIC
2.16.840.1.113883.10.20.22.2.12 Containment ReasonforVisitSection DYNAMIC
1.3.6.1.4.1.19376.1.5.3.1.3.18 Containment ReviewofSystemsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.17 Containment SocialHistorySection DYNAMIC
2.16.840.1.113883.10.20.22.2.36 Containment PostprocedureDiagnosisSection DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent. (ProcedureNote)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8496) such that it conf‑8496
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.6
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17182). conf‑17182
treetree cda:participant
0 .. * MAY contain zero or more [0..*] participant (CONF:8504) such that it conf‑8504
treeblank treetree @typeCode
1 .. 1 F IND
treeblank treetree cda:functionCode
1 .. 1 M SHALL contain exactly one [1..1] functionCode="PCP" Primary Care Physician (CodeSystem: participationFunction 2.16.840.1.113883.5.88 STATIC) (CONF:8506). conf‑8506
treeblank treetree cda:associatedEntity/@classCode
1 .. 1 M SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8507). conf‑8507
  Schematron assert role red error
  test not(cda:associatedEntity[@classCode='PROV']) or cda:associatedEntity[@classCode='PROV']
  Message SHALL contain exactly one [1..1] associatedEntity/@classCode="PROV" Provider (CodeSystem: HL7ParticipationType 2.16.840.1.113883.5.90 STATIC) (CONF:8507).
treeblank treeblank treetree cda:associatedPerson
1 .. 1 M This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:8508). conf‑8508
  Schematron assert role red error
  test not(cda:participant[@typeCode='IND'][@classCode='PROV']/cda:associatedEntity[cda:functionCode]) or cda:participant[@typeCode='IND'][@classCode='PROV']/cda:associatedEntity[cda:functionCode][count(cda:associatedPerson)=1]
  Message This associatedEntity/@classCode SHALL contain exactly one [1..1] associatedPerson (CONF:8508).
treetree cda:documentationOf
1 .. * M SHALL contain at least one [1..*] documentationOf (CONF:8510) such that it

Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF).
conf‑8510
treeblank treetree cda:serviceEvent
1 .. 1 M SHALL contain exactly one [1..1] serviceEvent (CONF:10061).

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.
conf‑10061
treeblank treeblank treetree cda:effectiveTime
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:10062).

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 present

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‑10062
treeblank treeblank treeblank treetree cda:low
1 .. 1 M This effectiveTime SHALL contain exactly one [1..1] low (CONF:26449). conf‑26449
  Schematron assert role red error
  test cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:low
  Message The serviceEvent/effectiveTime SHALL be present with effectiveTime/low
  Schematron assert role red error
  test count(cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:high | cda:documentationOf/cda:serviceEvent/cda:effectiveTime/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:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:high | cda:documentationOf/cda:serviceEvent/cda:effectiveTime/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
  Schematron assert role red error
  test string-length(cda:documentationOf/cda:serviceEvent/cda:effectiveTime//@value)>=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)
treeblank treeblank treetree cda:performer
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8520). conf‑8520
treeblank treeblank treeblank treetree @typeCode
1 .. 1 F PPRF
treeblank treeblank treeblank treetree cda:assignedEntity
1 .. 1 M This performer SHALL contain exactly one [1..1] assignedEntity (CONF:14911). conf‑14911
treeblank treeblank treeblank treeblank treetree cda:code
0 .. 1 R This assignedEntity SHOULD contain zero or one [0..1] code (CONF:14912). conf‑14912
  Schematron assert role red error
  test cda:documentationOf/cda:serviceEvent/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.
treetree cda:component
1 .. 1 M SHALL contain exactly one [1..1] component (CONF:9588).

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

SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section.

Each section SHALL have a title and the title SHALL NOT be empty

SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present

SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section
conf‑9588
  Schematron assert role red error
  test count(cda:component/cda:structuredBody | cda:component/cda:nonXMLBody) = 1
  Message A Procedure Note can have either a structuredBody or a nonXMLBody
  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:templateId[@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:templateId[@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.
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treeblank treetree cda:nonXMLBody
conf‑9588
treeblank treeblank treetree cda:structuredBody
conf‑9588
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.8']]
0 .. 1 conf‑9645
  Contains 2.16.840.1.113883.10.20.22.2.8 Assessment Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
0 .. 1 conf‑9647
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.9']]
0 .. 1 conf‑9649
  Contains 2.16.840.1.113883.10.20.22.2.9 Assessment and Plan Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.37']]
1 .. 1 M conf‑9802
  Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.27']]
1 .. 1 M conf‑9805
  Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.29']]
1 .. 1 M conf‑9807
  Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.6']]
0 .. 1 conf‑9809
  Contains 2.16.840.1.113883.10.20.22.2.6 Allergies Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.25']]
0 .. 1 conf‑9811
  Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1']]
0 .. 1 conf‑9813
  Contains 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1 Chief Complaint Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.13']]
0 .. 1 conf‑9815
  Contains 2.16.840.1.113883.10.20.22.2.13 Chief Complaint and Reason for Visit Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.15']]
0 .. 1 conf‑9817
  Contains 2.16.840.1.113883.10.20.22.2.15 Family History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.20']]
0 .. 1 conf‑9819
  Contains 2.16.840.1.113883.10.20.22.2.20 History of Past Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.4']]
0 .. 1 conf‑9821
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.4 History of Present Illness Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.39']]
0 .. 1 conf‑9823
  Contains 2.16.840.1.113883.10.20.22.2.39 Medical (General) History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.1']]
0 .. 1 conf‑9825
  Contains 2.16.840.1.113883.10.20.22.2.1 Medications Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.38']]
0 .. 1 conf‑9827
  Contains 2.16.840.1.113883.10.20.22.2.38 Medications Administered Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.2.10']]
0 .. 1 conf‑9829
  Contains 2.16.840.1.113883.10.20.2.10 Physical Exam Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.30']]
0 .. 1 conf‑9831
  Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.18.2.12']]
0 .. 1 conf‑9833
  Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.18.2.9']]
0 .. 1 conf‑9835
  Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.28']]
0 .. 1 conf‑9837
  Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.40']]
0 .. 1 conf‑9839
  Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.31']]
0 .. 1 conf‑9841
  Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.7']]
0 .. 1 conf‑9843
  Contains 2.16.840.1.113883.10.20.22.2.7 Procedures Section (entries optional) (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.12']]
0 .. 1 conf‑9845
  Contains 2.16.840.1.113883.10.20.22.2.12 Reason for Visit Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.3.18']]
0 .. 1 conf‑9847
  Contains 1.3.6.1.4.1.19376.1.5.3.1.3.18 Review of Systems Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.17']]
0 .. 1 conf‑9849
  Contains 2.16.840.1.113883.10.20.22.2.17 Social History Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.36']]
1 .. 1 M conf‑9850
  Contains 2.16.840.1.113883.10.20.22.2.36 Postprocedure Diagnosis Section (DYNAMIC)
  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:templateId[@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:templateId[@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
treetree cda:componentOf/encompassingEncounter
0 .. 1 R SHOULD contain zero or one [0..1] componentOf/encompassingEncounter (CONF:8499). conf‑8499
treeblank treetree cda:location/healthCareFacility/id
1 .. * M The componentOf/encompassingEncounter, if present, SHALL contain at least one [1..*] location/healthCareFacility/id (CONF:8500). conf‑8500
treeblank treetree cda:code
1 .. 1 M The componentOf/encompassingEncounter, if present, SHALL contain exactly one [1..1] code (CONF:8501). conf‑8501
treeblank treetree cda:encounterParticipant
0 .. 1 The componentOf/encompassingEncounter, if present, MAY contain zero or one [0..1] encounterParticipant (CONF:8502) such that it conf‑8502
treeblank treeblank treetree @typeCode
1 .. 1 F REF