Template 2.16.840.1.113883.10.20.22.4.14 - ProcedureActivityProcedureV2

Template Procedure Activity Procedure (V2)

2.16.840.1.113883.10.20.22.4.14

ref

ccda-

Effective Date

2014‑06‑09

Other versions this id:

ProcedureActivityProcedureV2 as of 2019‑03‑06 15:51:00

Status Under pre-publication review 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.

Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.14

Classification CDA Entry Level Template

Open/Closed Open (other than defined elements are allowed)

Used by / Uses

Used by 0 transactions and 22 templates, Uses 7 templates

Used by	as	Name	Version
2.16.840.1.113883.10.20.22.2.58	Containment	Reaction Observation (V2) (2.1)	2019‑03‑08 05:57:43
	Circular reference found with ReactionObservationV2, please check
2.16.840.1.113883.10.20.22.2.77		BC CDA Allergy - Intolerance Observation (V2) (2.1)	2019‑03‑31 09:08:58
2.16.840.1.113883.10.20.22.2.61		BC CDA Allergy Concern Act (V3) (2.1)	2019‑03‑15 13:09:01
2.16.840.1.113883.10.20.22.2.62		BC CDA Allergies and Intolerances Section (entries optional) (V3) (2.1)	2019‑03‑15 13:13:08
2.16.840.1.113883.3.51.60.2.4.1		BC CDA ClinicalDocumentDischargeSummary (V3) (2.1)	2019‑03‑19 14:15:51
2.16.840.1.113883.10.20.22.2.83		Medication Activity (V2) (2.1)	2019‑03‑31 19:39:08
2.16.840.1.113883.10.20.22.2.82		Discharge Medication (V2) (2.1)	2019‑03‑31 19:24:50
2.16.840.1.113883.10.20.22.2.11		BC CDA Discharge Medications Section (entries optional) (V3) (2.1)	2019‑03‑15 14:34:42
2.16.840.1.113883.10.20.22.2.89		Admission Medication (V2) (2.1)	2019‑04‑01 01:46:48
2.16.840.1.113883.10.20.22.2.43		Admission Diagnosis Section (V3) (2.1)	2019‑03‑16 20:59:38
2.16.840.1.113883.10.20.22.2.44		BC CDA Admission Medications Section (entries optional) (V3) (2.1)	2019‑03‑16 21:05:50
2.16.840.1.113883.10.20.22.2.90		Immunization Activity (V3) (2.1)	2019‑04‑01 01:57:35
2.16.840.1.113883.10.20.22.2.78		Immunizations Section (entries optional) (V3) (2.1)	2019‑03‑16 21:11:13
2.16.840.1.113883.10.20.22.2.7	Containment	Procedures Section (entries optional) (V2) (2.1)	2019‑03‑16 21:12:43
2.16.840.1.113883.10.20.22.4.9	Containment	Reaction Observation (V2) (2.1)	2014‑06‑09
	Circular reference found with 2.16.840.1.113883.10.20.22.4.9, please check
2.16.840.1.113883.10.20.22.2.73		Procedure Activity Procedure (V2) (2.1)	2019‑03‑06 15:51:00
2.16.840.1.113883.10.20.22.2.95		Result Organizer (V3) (2.1)	2019‑04‑03 23:40:21
2.16.840.1.113883.10.20.22.2.47		BC CDA Results Section (entries optional) (V3) (2.1)	2019‑03‑16 19:55:12
2.16.840.1.113883.10.20.22.4.13		Procedure Activity Observation (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.4.14		Procedure Activity Procedure (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.4.16		Medication Activity (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.4.12		Procedure Activity Act (V2) (2.1)	2014‑06‑09
Uses	as	Name	Version
2.16.840.1.113883.10.20.22.4.119	Containment	Author Participation (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.4.37	Containment	Product Instance (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.4.32	Containment	Service Delivery Location (2.1)	2015‑08‑13
2.16.840.1.113883.10.20.22.4.20	Containment	Instruction (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.4.19	Containment	Indication (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.4.16	Containment	Medication Activity (V2) (2.1)	2014‑06‑09
2.16.840.1.113883.10.20.22.4.9	Containment	Reaction Observation (V2) (2.1)	2014‑06‑09

Relationship

Specialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)

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ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.14 Procedure Activity Procedure (2013‑01‑31)

ref

ccda-

Item DT Card Conf Description Label

cda:procedure

(ProeV2)

@classCode

1 … 1

PROC

CONF7652

SHALL contain exactly one [1..1] @classCode="PROC" Procedure (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-7652).

@moodCode

1 … 1

EVN

CONF7653

SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001 STATIC) (CONF:1098-7653).

cda:templateId

1 … 1

SHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that it

CONF7654

@root

1 … 1

2.16.840.1.113883.10.20.22.4.14

CONF0521

SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14" (CONF:1098-10521).

@extension

1 … 1

2014-06-09

CONF2506

SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506).

cda:id

1 … *

SHALL contain at least one [1..*] id (CONF:1098-7655).

CONF7655

cda:code

1 … 1

SHALL contain exactly one [1..1] code (CONF:1098-7656).

CONF7656

cda:originalText

0 … 1

This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203).

CONF9203

cda:reference

0 … 1

The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19204).

CONF9204

@value

0 … 1

The reference, if present, SHOULD contain zero or one [0..1] @value (CONF:1098-19205).

CONF9205

Schematron assert role 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).

cda:statusCode

1 … 1

SHALL contain exactly one [1..1] statusCode (CONF:1098-7661).

CONF7661

cda:effectiveTime

0 … 1

SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662).

CONF7662

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).

CONF7668

CONF

The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)

cda:methodCode

0 … 1

MAY contain zero or one [0..1] methodCode (CONF:1098-7670).

CONF7670

Constraint methodCode *SHALL NOT* conflict with the method inherent in Procedure / code.

cda:targetSiteCode

0 … *

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.

CONF7683

@code

1 … 1

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).

CONF6082

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)

cda:specimen

0 … *

MAY contain zero or more [0..*] specimen (CONF:1098-7697).

CONF7697

Constraint This specimen is for representing specimens obtained from a procedure.

cda:specimenRole

1 … 1

The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:1098-7704).

CONF7704

cda:id

0 … *

This specimenRole SHOULD contain zero or more [0..*] id (CONF:1098-7716).

CONF7716

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

cda:performer

0 … *

SHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that it

CONF7718

cda:assignedEntity

1 … 1

SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720).

CONF7720

cda:id

1 … *

This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722).

CONF7722

cda:addr

1 … *

This assignedEntity SHALL contain at least one [1..*] addr (CONF:1098-7731).

CONF7731

cda:telecom

TEL

1 … *

This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1098-7732).

CONF7732

cda:representedOrganization

0 … 1

This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-7733).

CONF7733

cda:id

0 … *

The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-7734).

CONF7734

cda:name

0 … *

The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-7735).

CONF7735

cda:telecom

TEL

1 … 1

The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-7737).

CONF7737

cda:addr

1 … 1

The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-7736).

CONF7736

cda:author

1 … *

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 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13)

CONF2479

where [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.119']]

cda:participant

0 … *

Contains 2.16.840.1.113883.10.20.22.4.37 Product Instance (2015‑08‑13)

CONF7751

where [cda:participantRole [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.37']]]

@typeCode

1 … 1

DEV

CONF7752

SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002 STATIC) (CONF:1098-7752).

cda:participant

0 … *

Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2015‑08‑13)

CONF7765

where [cda:participantRole [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.32']]]

@typeCode

1 … 1

LOC

CONF7766

SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1098-7766).

cda:entryRelationship

0 … *

MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) such that it

CONF7768

@typeCode

1 … 1

COMP

CONF7769

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).

@inversionInd

1 … 1

true

CONF8009

SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009).

cda:encounter

1 … 1

SHALL contain exactly one [1..1] encounter (CONF:1098-7770).

CONF7770

@classCode

1 … 1

ENC

CONF7771

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).

@moodCode

1 … 1

EVN

CONF7772

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).

cda:id

1 … 1

This encounter SHALL contain exactly one [1..1] id (CONF:1098-7773).

CONF7773

Constraint Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter.

cda:entryRelationship

0 … 1

Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09)

CONF7775

where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.20'] [@extension = '2014-06-09']]]

@typeCode

1 … 1

SUBJ

CONF7776

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).

@inversionInd

1 … 1

true

CONF7777

SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-7777).

cda:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09)

CONF7779

where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.19'] [@extension = '2014-06-09']]]

@typeCode

1 … 1

RSON

CONF7780

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).

cda:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (V2) (2014‑06‑09)

CONF7886

where [cda:substanceAdministration [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.16'] [@extension = '2014-06-09']]]

@typeCode

1 … 1

COMP

CONF7887

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).

cda:entryRelationship

0 … *

Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09)

CONF2473

where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.9'] [@extension = '2014-06-09']]]

@typeCode

1 … 1

COMP

CONF2474

SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32474).

Template Procedure Activity Procedure (V2)