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pending Template  Procedure Activity Procedure

Template 2.16.840.1.113883.10.20.22.4.14 - ProcedureActivityProcedure
Id 2.16.840.1.113883.10.20.22.4.14
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 2.16.840.1.113883.10.20.22.4.14
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 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.
Used by / Uses
Used by / Uses 85 templates
Used by Template id as Name Version
2.16.840.1.113883.10.20.22.2.25 Containment AnesthesiaSection Anesthesia Section 2013‑01‑31
2.16.840.1.113883.10.20.22.1.6 link ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883.10.20.22.1.7 link OperativeNote Operative Note 2013‑01‑31
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
2.16.840.1.113883.10.20.22.1.8 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
2.16.840.1.113883.10.20.22.4.9 Containment ReactionObservation Reaction Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.16 link MedicationActivity Medication Activity 2013‑01‑31
2.16.840.1.113883.10.20.22.2.1 link MedicationsSectionentriesoptional Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.1.9 link ProgressNote Progress Note 2013‑01‑31
2.16.840.1.113883.10.20.22.2.1.1 link MedicationsSectionentriesrequired Medications Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.38 link MedicationsAdministeredSection Medications Administered Section 2013‑01‑31
2.16.840.1.113883.10.20.22.4.12 link ProcedureActivityAct Procedure Activity Act 2013‑01‑31
2.16.840.1.113883.10.20.22.4.13 link ProcedureActivityObservation Procedure Activity Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.14 link ProcedureActivityProcedure Procedure Activity Procedure 2013‑01‑31
2.16.840.1.113883.10.20.22.4.35 link DischargeMedication Discharge Medication 2013‑01‑31
2.16.840.1.113883.10.20.22.2.11 link HospitalDischargeMedicationsSectionentriesoptional Hospital Discharge Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.11.1 link HospitalDischargeMedicationsSectionentriesrequired Hospital Discharge Medications Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.36 link AdmissionMedication Admission Medication 2013‑01‑31
2.16.840.1.113883.10.20.22.2.44 link HospitalAdmissionMedicationsSectionentriesoptional Hospital Admission Medications Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.52 link ImmunizationActivity Immunization Activity 2013‑01‑31
2.16.840.1.113883.10.20.22.2.2 link ImmunizationsSectionentriesoptional Immunizations Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.2.1 link ImmunizationsSectionentriesrequired Immunizations Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.22.4.7 link Allergy-IntoleranceObservation Allergy - Intolerance Observation 2013‑01‑31
2.16.840.1.113883.10.20.22.4.30 link AllergyProblemAct Allergy Problem Act 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6 link AllergiesSectionentriesoptional Allergies Section (entries optional) 2013‑01‑31
2.16.840.1.113883.10.20.22.2.6.1 link AllergiesSectionentriesrequired Allergies Section (entries required) 2013‑01‑31
2.16.840.1.113883.10.20.24.3.90 link SubstanceorDeviceAllergy-IntoleranceObservation Substance or Device Allergy - Intolerance Observation 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.4.37 Containment ProductInstance DYNAMIC
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
Item DT Card Conf Description Label
cda:procedure
(ProcedureActivityProcedure)
treetree @classCode
1 .. 1 F PROC
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:7654) such that it conf‑7654
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.4.14
treetree cda:id
1 .. * M SHALL contain at least one [1..*] id (CONF:7655). conf‑7655
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:7656). conf‑7656
treeblank treetree cda:originalText
0 .. 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:19203). conf‑19203
treeblank treeblank treetree cda:reference
0 .. 1 R 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).
conf‑19204
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:7661). conf‑7661
  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:7662). conf‑7662
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:7668). conf‑7668
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 Act Priority (DYNAMIC)
treetree cda:methodCode
CE 0 .. 1 MAY contain zero or one [0..1] methodCode (CONF:7670).

methodCode SHALL NOT conflict with the method inherent in Procedure / code.
conf‑7670
treetree cda:targetSiteCode
0 .. * R SHOULD contain zero or more [0..*] targetSiteCode (CONF:7683). conf‑7683
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:specimen
0 .. * MAY contain zero or more [0..*] specimen (CONF:7697).

This specimen is for representing specimens obtained from a procedure.
conf‑7697
treeblank treetree cda:specimenRole
1 .. 1 M The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:7704). conf‑7704
treeblank treeblank treetree cda:id
0 .. * R 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
treetree cda:performer
0 .. * R SHOULD contain zero or more [0..*] performer (CONF:7718) such that it conf‑7718
treeblank treetree cda:assignedEntity
1 .. 1 M SHALL contain exactly one [1..1] assignedEntity (CONF:7720). conf‑7720
treeblank treeblank treetree cda:id
1 .. * M This assignedEntity SHALL contain at least one [1..*] id (CONF:7722). conf‑7722
treeblank treeblank treetree cda:addr
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] addr (CONF:7731). conf‑7731
treeblank treeblank treetree cda:telecom
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:7732). conf‑7732
treeblank treeblank treetree cda:representedOrganization
0 .. 1 R This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:7733). conf‑7733
treeblank treeblank treeblank treetree cda:id
0 .. * R The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:7734). conf‑7734
treeblank treeblank treeblank treetree cda:name
0 .. * The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:7735). conf‑7735
treeblank treeblank treeblank treetree cda:telecom
1 .. 1 M The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:7737). conf‑7737
treeblank treeblank treeblank treetree cda:addr
1 .. 1 M The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:7736). conf‑7736
treetree cda:participant
where
[cda:participantRole [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.37']]
0 .. * conf‑7751
treeblank treetree @typeCode
1 .. 1 F DEV
  Contains 2.16.840.1.113883.10.20.22.4.37 Product Instance (DYNAMIC)
treetree cda:participant
where
[cda:participantRole [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.32']]
0 .. * conf‑7765
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:7768) such that it conf‑7768
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:7770). conf‑7770
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:7773).

Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.
conf‑7773
treetree cda:entryRelationship
where
[cda:act [cda:templateId/@root='2.16.840.1.113883.10.20.22.4.20']]
0 .. 1 conf‑7775
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‑7779
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‑7886
treeblank treetree @typeCode
1 .. 1 F COMP
  Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (DYNAMIC)