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pending Template  Procedure Description Section

Template 2.16.840.1.113883. - ProcedureDescriptionSection
Id 2.16.840.1.113883.
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Section Level Template
Context Parent nodes of template element with id 2.16.840.1.113883.
Open/Closed Open (other than defined elements are allowed)
Description The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty.
Used by / Uses
Used by / Uses 2 templates
Used by Template id as Name Version
2.16.840.1.113883. Containment ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883. Containment OperativeNote Operative Note 2013‑01‑31
Item DT Card Conf Description Label
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8062) such that it conf‑8062
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:15411). conf‑15411
treeblank treetree @code
1 .. 1 F 29554-3
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:title
1 .. 1 M SHALL contain exactly one [1..1] title (CONF:8064). conf‑8064
treetree cda:text
1 .. 1 M SHALL contain exactly one [1..1] text (CONF:8065). conf‑8065