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draft Template  Procedure Activity Procedure (V2)

Id 2.16.840.1.113883.10.20.22.4.14
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ccda-
 		Effective Date 2014‑06‑09
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.
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 4 templates, Uses 7 templates
Used by as Name Version
2.16.840.1.113883.10.20.22.4.9 Containment draft Reaction Observation (V2) (2.1) 2014‑06‑09
notice Circular reference found with 2.16.840.1.113883.10.20.22.4.9, please check
2.16.840.1.113883.10.20.22.4.14 link draft Procedure Activity Procedure (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.16 link draft Medication Activity (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.52 link draft Immunization Activity (V3) (2.1) 2015‑08‑01
Uses as Name Version
2.16.840.1.113883.10.20.22.4.119 Containment draft Author Participation (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.37 Containment draft Product Instance (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.32 Containment draft Service Delivery Location (2.1) 2015‑08‑13
2.16.840.1.113883.10.20.22.4.20 Containment draft Instruction (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.19 Containment draft Indication (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.16 Containment draft Medication Activity (V2) (2.1) 2014‑06‑09
2.16.840.1.113883.10.20.22.4.9 Containment draft 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)
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ccda-
Item DT Card Conf Description Label
cda:procedure
 		(ProdotseV2)
@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).
@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).
cda:templateId
 		II 1 … 1 M C-CDA R1.1 templateId root without an extension CONFdots2936
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.14
cda:templateId
 		II 1 … 1 M SHALL contain exactly one [1..1] templateId (CONF:1098-7654) such that it CONFdots7654
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.22.4.14 CONFdots0521
  SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14" (CONF:1098-10521).
@extension
 		st 1 … 1 F 2014-06-09 CONFdots2506
  SHALL contain exactly one [1..1] @extension="2014-06-09" (CONF:1098-32506).
cda:id
 		II 1 … * SHALL contain at least one [1..*] id (CONF:1098-7655). CONFdots7655
cda:code
 		1 … 1 SHALL contain exactly one [1..1] code (CONF:1098-7656). CONFdots7656
cda:originalText
 		0 … 1 R This code SHOULD contain zero or one [0..1] originalText (CONF:1098-19203). CONFdots9203
cda:reference
 		0 … 1 R The originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:1098-19204). CONFdots9204
@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).  
cda:statusCode
 		CS 1 … 1 R SHALL contain exactly one [1..1] statusCode (CONF:1098-7661). CONFdots7661
cda:effectiveTime
 		0 … 1 R SHOULD contain zero or one [0..1] effectiveTime (CONF:1098-7662). CONFdots7662
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)
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.
cda:targetSiteCode
 		0 … * R

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.

SHOULD contain zero or more [0..*] targetSiteCode,  which SHALL be selected from ValueSe t Body Site urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:1098-7683)

CONFdots7683
  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). CONFdots7697
  Constraint This specimen is for representing specimens obtained from a procedure.
cda:specimenRole
 		1 … 1 M The specimen, if present, SHALL contain exactly one [1..1] specimenRole (CONF:1098-7704). CONFdots7704
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
cda:performer
 		0 … * R SHOULD contain zero or more [0..*] performer (CONF:1098-7718) such that it CONFdots7718
cda:assignedEntity
 		1 … 1 M SHALL contain exactly one [1..1] assignedEntity (CONF:1098-7720). CONFdots7720
cda:id
 		II 1 … * This assignedEntity SHALL contain at least one [1..*] id (CONF:1098-7722). CONFdots7722
cda:addr
 		AD 1 … * This assignedEntity SHALL contain at least one [1..*] addr (CONF:1098-7731). CONFdots7731
cda:telecom
 		TEL 1 … * This assignedEntity SHALL contain at least one [1..*] telecom (CONF:1098-7732). CONFdots7732
cda:representedOrganization
 		0 … 1 R This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:1098-7733). CONFdots7733
cda:id
 		II 0 … * R The representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:1098-7734). CONFdots7734
cda:name
 		0 … * The representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:1098-7735). CONFdots7735
cda:telecom
 		TEL 1 … 1 The representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:1098-7737). CONFdots7737
cda:addr
 		AD 1 … 1 The representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:1098-7736). CONFdots7736
cda:author
 		0 … * SHOULD contain zero or more [0..*] 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) 		CONFdots2479
cda:participant
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.37 Product Instance (2015‑08‑13) CONFdots7751
@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).
cda:participant
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.32 Service Delivery Location (2015‑08‑13) CONFdots7765
@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).
cda:entryRelationship
 		0 … * MAY contain zero or more [0..*] entryRelationship (CONF:1098-7768) such that it CONFdots7768
@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).
@inversionInd
 		bl 1 … 1 F true CONFdots8009
  SHALL contain exactly one [1..1] @inversionInd="true" true (CONF:1098-8009).
cda:encounter
 		1 … 1 M SHALL contain exactly one [1..1] encounter (CONF:1098-7770). CONFdots7770
@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).
@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).
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.
cda:entryRelationship
 		0 … 1 Contains 2.16.840.1.113883.10.20.22.4.20 Instruction (V2) (2014‑06‑09) CONFdots7775
@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).
@inversionInd
 		bl 1 … 1 F true CONFdots7777
  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) CONFdots7779
@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).
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.16 Medication Activity (V2) (2014‑06‑09) CONFdots7886
@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).
cda:entryRelationship
 		0 … * Contains 2.16.840.1.113883.10.20.22.4.9 Reaction Observation (V2) (2014‑06‑09) CONFdots2473
@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).