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pending Template  Procedure Activity Act

Template 2.16.840.1.113883.10.20.22.4.12 - ProcedureActivityAct
Id 2.16.840.1.113883.10.20.22.4.12
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Entry Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.12
Open/Closed Open (other than defined elements are allowed)
Description 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 any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures.
Used by / Uses
Used by / Uses 11 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.7 Containment ProceduresSectionentriesoptional Procedures Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.3 link HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883.10.20.22.1.4 link ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.6 link ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.8 link DischargeSummary Discharge Summary 2013‑01‑31
2.16.840.1.113883.10.20.22.2.7.1 Containment ProceduresSectionentriesrequired Procedures Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.2 link ContinuityofCareDocumentCCD Continuity of Care Document (CCD) 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.32 Containment ServiceDeliveryLocation DYNAMIC
2.16.840.1.113883.10.20.22.4.20 Containment Instructions DYNAMIC
2.16.840.1.113883.10.20.22.4.19 Containment Indication DYNAMIC
2.16.840.1.113883.10.20.22.4.16 Containment MedicationActivity DYNAMIC
Item DT Card Conf Description Label
cda:act
(ProcedureActivityAct)
treetree @classCode
1 .. 1 F ACT
treetree @moodCode
1 .. 1 R
  CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.18 MoodCodeEvnInt (DYNAMIC)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8291) such that it conf‑8291
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.12
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:8292). conf‑8292
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:8293). conf‑8293
treeblank treetree cda:originalText
0 .. 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:19186). conf‑19186
treeblank treeblank treetree cda:reference
0 .. 1 The originalText, if present, MAY contain zero or one [0..1] reference (CONF:19187).

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)
conf‑19187
treeblank treeblank treeblank treetree @value
0 .. 1  
  Schematron assert role red error
  test count(cda:code/cda:originalText/cda:reference[@value])=0 or starts-with(cda:code/cda:originalText/cda:reference/@value, '#')
  Message 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)
treetree cda:statusCode
1 .. 1 M 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:8298). conf‑8298
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.9.22 ProcedureAct statusCode (DYNAMIC)
treetree cda:effectiveTime
0 .. 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:8299). conf‑8299
treetree cda:priorityCode
0 .. 1 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:8300). conf‑8300
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 Act Priority (DYNAMIC)
treetree cda:performer
0 .. * R SHOULD contain zero or more [0..*] performer (CONF:8301). conf‑8301
treeblank treetree cda:assignedEntity
1 .. 1 M The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8302). conf‑8302
treeblank treeblank treetree cda:id
1 .. * M This assignedEntity SHALL contain at least one [1..*] id (CONF:8303). conf‑8303
treeblank treeblank treetree cda:addr
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] addr (CONF:8304). conf‑8304
treeblank treeblank treetree cda:telecom
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:8305). conf‑8305
treeblank treeblank treetree cda:representedOrganization
0 .. 1 R This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8306). conf‑8306
treeblank treeblank treeblank treetree cda:id
0 .. * R The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:8307). conf‑8307
treeblank treeblank treeblank treetree cda:name
0 .. * The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:8308). conf‑8308
treeblank treeblank treeblank treetree cda:telecom
1 .. 1 M The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8310). conf‑8310
treeblank treeblank treeblank treetree cda:addr
1 .. 1 M The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:8309). conf‑8309
treetree cda:participant
where
[cda:participantRole [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.32']]
0 .. * conf‑8311
treeblank treetree @typeCode
1 .. 1 F LOC
  Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (DYNAMIC)
treetree cda:entryRelationship
0 .. * MAY contain zero or more [0..*] entryRelationship (CONF:8314) such that it conf‑8314
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree @inversionInd
1 .. 1 F true
treeblank treetree cda:encounter
1 .. 1 M SHALL contain exactly one [1..1] encounter (CONF:8317). conf‑8317
treeblank treeblank treetree @classCode
1 .. 1 F ENC
treeblank treeblank treetree @moodCode
1 .. 1 F EVN
treeblank treeblank treetree cda:id
1 .. 1 M This encounter SHALL contain exactly one [1..1] id (CONF:8320).

Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.
conf‑8320
treetree cda:entryRelationship
where
[cda:act [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.20']]
0 .. 1 conf‑8322
treeblank treetree @typeCode
1 .. 1 F SUBJ
treeblank treetree @inversionInd
1 .. 1 F true
  Contains 2.16.840.1.113883.10.20.22.4.20 Instructions (DYNAMIC)
treetree cda:entryRelationship
where
[cda:observation [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.19']]
0 .. * conf‑8326
treeblank treetree @typeCode
1 .. 1 F RSON
  Contains 2.16.840.1.113883.10.20.22.4.19 Indication (DYNAMIC)
treetree cda:entryRelationship
where
[cda:substanceAdministration [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.16']]
0 .. * conf‑8329
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (DYNAMIC)