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pending Template  Planned Observation (V2)

Id 2.16.840.1.113883.10.20.22.4.44
ref
ccda-
 		Effective Date 2014‑06‑09
Status pending Under pre-publication review Version Label 2.1
Name PlannedObservationV2 Display Name Planned Observation (V2)
Description
This template represents planned observations that result in new information about the patient which cannot be classified as a procedure according to the HL7 RIM, i.e., procedures alter the patient's body. Examples of these observations are laboratory tests, diagnostic imaging tests, EEGs, and EKGs. The importance of the planned observation to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the observation is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Observation template may also indicate the potential insurance coverage for the observation.
Context Parent nodes of template element with id 2.16.840.1.113883.10.20.22.4.44
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 2.16.840.1.113883.10.12.303 CDA Observation (2005‑09‑07)
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ad1bbr-

Version: template 2.16.840.1.113883.10.20.22.4.44 Plan of Care Activity Observation (2013‑01‑31)
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ccda-
Item DT Card Conf Description Label
cda:observation
(PladotsnV2)
treetree @classCode
1 … 1 F OBS CONFdots8581
  SHALL contain exactly one [1..1] @classCode="OBS" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:1098-8581).
treetree @moodCode
1 … 1 R SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Observation) urn:oid:2.16.840.1.113883.11.20.9.25 STATIC 2011-09-30 (CONF:1098-8582). CONFdots8582
  CONF
The value of @moodCode shall be drawn from value set 2.16.840.1.113883.11.20.9.25 Planned moodCode (Observation) (2011‑09‑30)
treetree cda:templateId
II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-30451) such that it CONFdots0451
treeblank treetree @root
1 … 1 F 2.16.840.1.113883.10.20.22.4.44 CONFdots0452
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.44" (CONF:1098-30452).
treeblank treetree @extension
1 … 1 F 2014-06-09 CONFdots2555
  SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32555).
treetree cda:id
II 1 … * SHALL contain at least one [1..*] id (CONF:1098-8584). CONFdots8584
treetree cda:code
CD 1 … 1 M SHALL contain exactly one [1..1] code, which SHOULD be selected from CodeSystem LOINC (urn:oid:2.16.840.1.113883.6.1) (CONF:1098-31030). CONFdots1030
treeblank treetree @codeSystem
CONF 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)
treetree cda:statusCode
CS 1 … 1 M SHALL contain exactly one [1..1] statusCode (CONF:1098-30453). CONFdots0453
treeblank treetree @code
CONF 1 … 1 F active
treetree cda:effectiveTime
IVL_TS 0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-30454).

The effectiveTime in a planned observation represents the time that the observation should occur. 		CONFdots0454
treetree cda:value
0 … 1 MAY contain zero or one [0..1] value (CONF:1098-31031). CONFdots1031
treetree cda:methodCode
0 … 1 MAY contain zero or one [0..1] methodCode (CONF:1098-32043).

In a planned observation the provider may suggest that an observation should be performed using a particular method. 		CONFdots2043
treetree cda:targetSiteCode
0 … * R SHOULD 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:1098-32044).

The targetSiteCode is used to identify the part of the body of concern for the planned observation. 		CONFdots2044
  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:1098-30456).

The clinician who is expected to perform the observation could be identified using procedure/performer. 		CONFdots0456
treetree cda:author
0 … * R SHOULD contain zero or more [0..*] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:1098-32033).

The author in a planned observation represents the clinician who is requesting or planning the observation.
Contains 2.16.840.1.113883.10.20.22.4.119 Author Participation (2015‑08‑13) 		CONFdots2033
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 observation.
Contains 2.16.840.1.113883.10.20.22.4.143 Priority Preference (2015‑08‑13) 		CONFdots1073
treeblank where [cda:observation [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.143']]]
treeblank treetree @typeCode
1 … 1 F REFR CONFdots1074
  SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-31074).
treetree cda:entryRelationship
0 … * The following entryRelationship represents the indication for the observation.
Contains 2.16.840.1.113883.10.20.22.4.19 Indication (V2) (2014‑06‑09) 		CONFdots2034
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 CONFdots2035
  SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32035).
treetree cda:entryRelationship
0 … * The following entryRelationship captures any instructions associated with the planned observation.
Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) 		CONFdots2037
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 CONFdots2038
  SHALL contain exactly one [1..1] @typeCode="SUBJ" Has subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32038).
treetree cda:entryRelationship
0 … * The following entryRelationship represents the insurance coverage the patient may have for the observation.
Contains 2.16.840.1.113883.10.20.22.4.129 Planned Coverage (2015‑08‑13) 		CONFdots2040
treeblank where [cda:act [cda:templateId [@root = '2.16.840.1.113883.10.20.22.4.129']]]
treeblank treetree @typeCode
1 … 1 F COMP CONFdots2041
  SHALL contain exactly one [1..1] @typeCode="COMP" Has Component (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1098-32041).