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draft Template  Procedure Activity Procedure (V2)

Id 2.16.840.1.113883.10.20.22.2.73 Effective Date 2019‑03‑06 15:51:00
Other versions this id:
Status draft Draft Version Label 2.1
Name ProcedureActivityProcedureV2 Display Name Procedure Activity Procedure (V2)
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 template 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. This template can be used with a contained Product Instance template to represent a device in or on a patient. In this case, targetSiteCode is used to record the location of the device in or on the patient's body. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity (V2) template.
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Used by / Uses
Used by 0 transactions and 3 templates, Uses 7 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.2.95 Containment draft Result Organizer (V3) (2.1) 2019‑04‑03 23:40:21
2.16.840.1.113883.10.20.22.2.47 link draft BC CDA Results Section (entries optional) (V3) (2.1) 2019‑03‑16 19:55:12
2.16.840.1.113883.3.51.60.2.4.1 link draft BC CDA ClinicalDocumentDischargeSummary (V3) (2.1) 2019‑03‑19 14:15:51
Uses as Name Version
2.16.840.1.113883.10.20.22.2.52 Containment draft Clinical Presentation Section (2.1) DYNAMIC
2.16.840.1.113883.10.20.22.4.37 Containment pending Product Instance (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.32 Containment pending Service Delivery Location (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.20 Containment pending Instruction (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.19 Containment pending Indication (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.16 Containment pending Medication Activity (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.9 Containment pending Reaction Observation (V2) (2.1) 2014‑06‑09
Relationship Specialization: template 2.16.840.1.113883.10.20.22.2.73 (2014‑06‑09)
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Specialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
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Version: template 2.16.840.1.113883.10.20.22.2.73 (2013‑01‑31)
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Item DT Card Conf Description Label
cda:procedure
(ProdotseV2)
treetree @classCode
cs 1 … 1 F PROC CONFdots7652
  SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7652).
treetree @moodCode
cs 1 … 1 F EVN CONFdots7653
  SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7653).
treetree hl7:templateId
II 1 … 1 M (ProdotseV2)
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.73
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that it CONFdots7654
treeblank treetree @root
uid 1 … 1 F 2.16.840.1.113883.10.20.22.2.73 CONFdots0521
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14" (CONF:1098-10521).
treeblank treetree @extension
st 1 … 1 F 2014-06-09 CONFdots2506
  SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:1098-7655). CONFdots7655
treetree cda:code
1 … 1 SHALL contain exactly one [1..1] code (CONF:1098-7656). CONFdots7656
treeblank treetree cda:originalText
0 … 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203). CONFdots9203
treeblank treeblank treetree cda:reference
0 … 1 R The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19204). CONFdots9204
treeblank treeblank treeblank treetree @value
0 … 1   The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19205). CONFdots9205
  Schematron assert role red error  
  test not(@value) or starts-with(@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
CS 1 … 1 R SHALL contain exactly one [1..1] statusCode (CONF:1098-7661). CONFdots7661
treetree cda:effectiveTime
0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662). CONFdots7662
treetree cda:priorityCode
0 … 1 MAY contain zero or one [0..1] priorityCode, which SHALL be selected from ValueSet Act Priority urn:oid:2.16.840.1.113883.1.11.16866 DYNAMIC (CONF:1098-7668). CONFdots7668
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
treetree cda:methodCode
0 … 1 MAY contain zero or one [0..1] methodCode (CONF:1098-7670). CONFdots7670
  Constraint methodCode *SHALL NOT* conflict with the method inherent in Procedure / code.
treetree cda:targetSiteCode
0 … * R SHOULD contain zero or more [0..*] targetSiteCode (CONF:1098-7683).

In the case of an implanted medical device, targetSiteCode is used to record the location of the device, in or on the patient's body.

CONFdots7683
treeblank treetree @code
1 … 1 R The targetSiteCode, if present, SHALL contain exactly one [1..1] @code, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-16082). CONFdots6082
treetree cda:specimen
0 … * MAY contain zero or more [0..*] specimen (CONF:1098-7697). CONFdots7697
  Constraint This specimen is for representing specimens obtained from a procedure.
treeblank treetree cda:specimenRole
1 … 1 M The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:1098-7704). CONFdots7704
treeblank treeblank treetree cda:id
II 0 … * R This specimenRole SHOULD contain zero or more [0..*] id (CONF:1098-7716). CONFdots7716
  Constraint 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
treetree cda:performer
0 … * R SHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that it CONFdots7718
treeblank treetree cda:assignedEntity
1 … 1 M SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720). CONFdots7720
treeblank treeblank treetree cda:id
II 1 … * This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722). CONFdots7722
treeblank treeblank treetree cda:addr
AD 1 … * This assignedEntity SHALL contain at least one [1..*] addr (CONF:1098-7731). CONFdots7731
treeblank treeblank treetree cda:telecom
TEL 1 … * This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1098-7732). CONFdots7732
treeblank treeblank treetree cda:representedOrganization
0 … 1 R This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-7733). CONFdots7733
treeblank treeblank treeblank treetree cda:id
II 0 … * R The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-7734). CONFdots7734
treeblank treeblank treeblank treetree cda:name
0 … * The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-7735). CONFdots7735
treeblank treeblank treeblank treetree cda:telecom
TEL 1 … 1 The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-7737). CONFdots7737
treeblank treeblank treeblank treetree cda:addr
AD 1 … 1 The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-7736). CONFdots7736
treetree cda:author
1 … * R SHOULD contain at least one [1..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32479).
Contains 2.16.840.1.113883.10.20.22.2.52 Clinical Presentation Section (DYNAMIC) 		CONFdots2479
treeblank where [cda:section [cda:templateId [@root = '2.16.840.1.113883.10.20.6.2.20']]]
treetree cda:participant
0 … * Contains 2.16.840.1.113883.10.20.22.4.37 Product Instance (2015‑08‑13) CONFdots7751
treeblank where [cda:participantRole [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.37']]]
treeblank treetree @typeCode
cs 1 … 1 F DEV CONFdots7752
  SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7752).
treetree cda:participant
0 … * Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2015‑08‑13) CONFdots7765
treeblank where [cda:participantRole [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.32']]]
treeblank treetree @typeCode
cs 1 … 1 F LOC CONFdots7766
  SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7766).
treetree cda:entryRelationship
0 … * MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) such that it CONFdots7768
treeblank treetree @typeCode
cs 1 … 1 F COMP CONFdots7769
  SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7769).
treeblank treetree @inversionInd
bl 1 … 1 F true CONFdots8009
  SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009).
treeblank treetree cda:encounter
1 … 1 M SHALL contain exactly one [1..1] encounter (CONF:1098-7770). CONFdots7770
treeblank treeblank treetree @classCode
cs 1 … 1 F ENC CONFdots7771
  This encounter SHALL contain exactly one [1..1] @classCode="ENC" Encounter (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7771).
treeblank treeblank treetree @moodCode
cs 1 … 1 F EVN CONFdots7772
  This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7772).
treeblank treeblank treetree cda:id
II 1 … 1 This encounter SHALL contain exactly one [1..1] id (CONF:1098-7773). CONFdots7773
  Constraint Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.
treetree cda:entryRelationship
0 … 1 Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) CONFdots7775
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.20'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
cs 1 … 1 F SUBJ CONFdots7776
  SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7776).
treeblank treetree @inversionInd
bl 1 … 1 F true CONFdots7777
  SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-7777).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) CONFdots7779
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.19'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
cs 1 … 1 F RSON CONFdots7780
  SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7780).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (V2) (2014‑06‑09) CONFdots7886
treeblank where [cda:substanceAdministration [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.16'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
cs 1 … 1 F COMP CONFdots7887
  SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7887).
treetree cda:entryRelationship
0 … * Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) CONFdots2473
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.9'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
cs 1 … 1 F COMP CONFdots2474
  SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32474).