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pending Template  Planned Procedure (V2)

Id 2.16.840.1.113883.10.20.22.4.41
ref
ccda-
 		Effective Date 2014‑06‑09
Status pending Under pre-publication review Version Label 2.1
Name PlannedProcedureV2 Display Name Planned Procedure (V2)
Description
This template represents planned alterations of the patient's physical condition. Examples of such procedures are tracheostomy, knee replacement, and craniectomy. The priority of the procedure to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the procedure is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Procedure Template may also indicate the potential insurance coverage for the procedure.
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.41
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 5 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.2.10 Containment draft Plan of Treatment Section (V2) (2.1) 2019‑03‑16 08:54:08
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
2.16.840.1.113883.10.20.22.4.130 Containment pending Nutrition Recommendation (2.1) 2015‑08‑13
Uses as Name Version
2.16.840.1.113883.10.20.22.4.119 Containment pending Author Participation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.143 Containment pending Priority Preference (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.19 Containment pending Indication (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.20 Containment pending Instruction (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.129 Containment pending Planned Coverage (2.1) 2015‑08‑13
Relationship Specialization: template 2.16.840.1.113883.10.12.306 CDA Procedure (2005‑09‑07)
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ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.41 Plan of Care Activity Procedure (2013‑01‑31)
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ccda-
Item DT Card Conf Description Label
cda:procedure
(PladotseV2)
treetree @classCode
1 … 1 F PROC CONFdots8568
  SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8568).
treetree @moodCode
1 … 1 R SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:1098-8569). CONFdots8569
  CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.23 Planned moodCode (Act/Encounter/Procedure) (2011‑09‑30)
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-30444) such that it CONFdots0444
treeblank treetree @root
1 … 1 F 2.16.840.1.113883.10.20.22.4.41 CONFdots0445
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.41" (CONF:1098-30445).
treeblank treetree @extension
1 … 1 F 2014-06-09 CONFdots2554
  SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32554).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:1098-8571). CONFdots8571
treetree cda:code
1 … 1 SHALL contain exactly one [1..1] code (CONF:1098-31976). CONFdots1976
treetree cda:statusCode
CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:1098-30446). CONFdots0446
treeblank treetree @code
CONF 1 … 1 F active
treetree cda:effectiveTime
0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30447).

The effectiveTime in a planned procedure represents the time that the procedure should occur. 		CONFdots0447
treetree cda:methodCode
0 … * MAY contain zero or more [0..*] methodCode (CONF:1098-31980).

In a planned procedure the provider may suggest that a procedure should be performed using a particular method. MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. 		CONFdots1980
treetree cda:targetSiteCode
0 … * MAY contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-31981).

The targetSiteCode is used to identify the part of the body of concern for the planned procedure. 		CONFdots1981
  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:performer
0 … * MAY contain zero or more [0..*] performer (CONF:1098-30449).

The clinician who is expected to perform the procedure could be identified using procedure/performer. 		CONFdots0449
treetree cda:author
0 … 1 R SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-31979).

The author in a planned procedure represents the clinician who is requesting or planning the procedure.
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) 		CONFdots1979
treeblank where [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.119']]
treetree cda:entryRelationship
0 … * The following entryRelationship represents the priority that a patient or a provider places on the procedure.
Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) 		CONFdots1079
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.143']]]
treeblank treetree @typeCode
1 … 1 F REFR CONFdots1080
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31080).
treetree cda:entryRelationship
0 … * The following entryRelationship represents the indication for the procedure.
Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) 		CONFdots1982
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.19'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F RSON CONFdots1983
  SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31983).
treetree cda:entryRelationship
0 … * The following entryRelationship captures any instructions associated with the planned procedure.
Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) 		CONFdots1985
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.20'] [@extension = '2014-06-09']]]
treeblank treetree @typeCode
1 … 1 F SUBJ CONFdots1986
  SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31986).
treeblank treetree @inversionInd
1 … 1 F true CONFdots1987
  SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:1098-31987).
treetree cda:entryRelationship
0 … * The following entryRelationship represents the insurance coverage the patient may have for the procedure.
Contains 2.16.840.1.113883.10.20.22.4.129 Planned Coverage (2015‑08‑13) 		CONFdots1990
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.129']]]
treeblank treetree @typeCode
1 … 1 F COMP CONFdots1991
  SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:1098-31991).