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pending Template  Procedures Section (entries optional)

Template 2.16.840.1.113883. - ProceduresSectionentriesoptional
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 This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section is intended to include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of ""procedure"" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change). The length of an encounter is documented in the documentationOf/encompassingEncounter/effectiveTime and length of service in documentationOf/ServiceEvent/effectiveTime.
Used by / Uses
Used by / Uses 7 templates
Used by Template id as Name Version
2.16.840.1.113883. Containment HistoryandPhysical History and Physical 2013‑01‑31
2.16.840.1.113883. Containment ConsultationNote Consultation Note 2013‑01‑31
2.16.840.1.113883. Containment ProcedureNote Procedure Note 2013‑01‑31
2.16.840.1.113883. Containment DischargeSummary Discharge Summary 2013‑01‑31
Uses Template id as Name Version
2.16.840.1.113883. Containment ProcedureActivityProcedure DYNAMIC
2.16.840.1.113883. Containment ProcedureActivityObservation DYNAMIC
2.16.840.1.113883. Containment ProcedureActivityAct DYNAMIC
Item DT Card Conf Description Label
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:6270) such that it conf‑6270
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:15423). conf‑15423
treeblank treetree @code
1 .. 1 F 47519-4
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:17184). conf‑17184
treetree cda:text
1 .. 1 M SHALL contain exactly one [1..1] text (CONF:6273). conf‑6273
treetree cda:entry
[cda:procedure [cda:templateId/@root='2.16.840.1.113883.']]
0 .. * conf‑6274
  Contains 2.16.840.1.113883. Procedure Activity Procedure (DYNAMIC)
treetree cda:entry
[cda:observation [cda:templateId/@root='2.16.840.1.113883.']]
0 .. 1 conf‑6278
  Contains 2.16.840.1.113883. Procedure Activity Observation (DYNAMIC)
treetree cda:entry
[cda:act [cda:templateId/@root='2.16.840.1.113883.']]
0 .. 1 conf‑8533
  Contains 2.16.840.1.113883. Procedure Activity Act (DYNAMIC)