Back To Index  <<  Back To Templates

pending Template  Procedure Activity Observation

Template 2.16.840.1.113883.10.20.22.4.13 - ProcedureActivityObservation
Id 2.16.840.1.113883.10.20.22.4.13
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 2.16.840.1.113883.10.20.22.4.13
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 procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.
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:observation
(ProcedureActivityObservation)
treetree @classCode
1 .. 1 F OBS
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:8238) such that it conf‑8238
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.13
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:8239). conf‑8239
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:19197). conf‑19197
treeblank treetree cda:originalText
0 .. 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:19198). conf‑19198
treeblank treeblank treetree cda:reference
0 .. 1 R The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:19199).

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‑19199
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:8245). conf‑8245
  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:8246). conf‑8246
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:8247). conf‑8247
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 Act Priority (DYNAMIC)
treetree cda:value
1 .. 1 M SHALL contain exactly one [1..1] value (CONF:16846). conf‑16846
treetree cda:methodCode
CE 0 .. 1 MAY contain zero or one [0..1] methodCode (CONF:8248).

methodCode SHALL NOT conflict with the method inherent in Observation / code.
conf‑8248
treetree cda:targetSiteCode
0 .. * R SHOULD contain zero or more [0..*] targetSiteCode (CONF:8250). conf‑8250
treeblank treetree @code
1 .. 1 R
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.8.9 Body Site (DYNAMIC)
treetree cda:performer
0 .. * R SHOULD contain zero or more [0..*] performer (CONF:8251). conf‑8251
treeblank treetree cda:assignedEntity
1 .. 1 M The performer, if present, SHALL contain exactly one [1..1] assignedEntity (CONF:8252). conf‑8252
treeblank treeblank treetree cda:id
1 .. * M This assignedEntity SHALL contain at least one [1..*] id (CONF:8253). conf‑8253
treeblank treeblank treetree cda:addr
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] addr (CONF:8254). conf‑8254
treeblank treeblank treetree cda:telecom
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:8255). conf‑8255
treeblank treeblank treetree cda:representedOrganization
0 .. 1 R This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8256). conf‑8256
treeblank treeblank treeblank treetree cda:id
0 .. * R The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:8257). conf‑8257
treeblank treeblank treeblank treetree cda:name
0 .. * The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:8258). conf‑8258
treeblank treeblank treeblank treetree cda:telecom
1 .. 1 M The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:8260). conf‑8260
treeblank treeblank treeblank treetree cda:addr
1 .. 1 M The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:8259). conf‑8259
treetree cda:participant
where
[cda:participantRole [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.32']]
0 .. * conf‑8261
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:8264). conf‑8264
treeblank treetree @typeCode
1 .. 1 F COMP
treeblank treetree @inversionInd
1 .. 1 F true
treeblank treetree cda:encounter
1 .. 1 M The entryRelationship, if present, SHALL contain exactly one [1..1] encounter (CONF:8267). conf‑8267
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:8270).

Set encounter/id to the id of an encounter in another section to signify they are the same encounter.
conf‑8270
treetree cda:entryRelationship
where
[cda:act [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.20']]
0 .. 1 conf‑8272
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‑8276
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‑8279
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (DYNAMIC)