| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ClinicalDocument
|
USRealmHeaderV4 |
XML Namespace:
urn:hl7-org:v3 This logical model cannot be the target of a reference |
||
Slices for templateId
|
2 .. | Slice: Unordered, Open by value:root, value:extension | ||
templateId:secondary
|
1..1 | |||
root
|
1..1 | Required Pattern: 2.16.840.1.113883.10.20.22.1.6 | ||
extension
|
1..1 | Required Pattern: 2015-08-01 | ||
|
code
|
1..1 | The Procedure Note recommends use of a single document type code, 28570-0 "Procedure Note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | ||
code
|
1..1 | Binding: ProcedureNoteDocumentTypeCodes ( required ) | ||
|
Slices for participant
|
The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:associatedEntity.classCode, value:typeCode, value:functionCode |
|||
|
participant:participant1
|
0..* | |||
|
typeCode
|
1..1 | Fixed Value: IND | ||
|
functionCode
|
1..1 | |||
code
|
1..1 | Required Pattern: PCP | ||
|
associatedEntity
|
||||
|
classCode
|
1..1 | Fixed Value: PROV | ||
|
associatedPerson
|
1..1 | |||
|
Slices for documentationOf
|
1 .. |
A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.
Slice: Unordered, Open by value:serviceEvent |
||
|
documentationOf:documentationOf1
|
1..* | |||
|
serviceEvent
|
C | 1..1 | 1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), CPT-4 (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511). | |
effectiveTime
|
C | 1..1 | http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS |
1198-8513:
The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8513). 1198-8514: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-8514). 1198-8515: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-8515). |
|
low
|
1..1 | |||
|
Slices for performer
|
1 .. |
This performer identifies any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode |
||
performer:performer1
|
1..1 | This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. | ||
typeCode
|
1..1 | Fixed Value: PPRF | ||
|
assignedEntity
|
1..1 | |||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( required ) | ||
|
performer:performer2
|
0..* | |||
|
typeCode
|
1..1 | Fixed Value: SPRF | ||
|
assignedEntity
|
1..1 | |||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( required ) | ||
|
authorization
|
0..1 | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. | ||
|
typeCode
|
1..1 | Fixed Value: AUTH | ||
|
consent
|
1..1 | |||
|
classCode
|
1..1 | Fixed Value: CONS | ||
|
moodCode
|
1..1 | Fixed Value: EVN | ||
|
statusCode
|
1..1 | |||
|
componentOf
|
0..1 | |||
|
encompassingEncounter
|
1..1 | |||
|
id
|
..* |
SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0 |
||
|
code
|
1..1 | |||
|
Slices for encounterParticipant
|
Slice: Unordered, Open by value:typeCode | |||
|
encounterParticipant:encounterParticipant1
|
0..1 | |||
|
typeCode
|
1..1 | Fixed Value: REF | ||
|
location
|
1.. | SG 20230709: EncompassingEncounter.location can have a maximum of 1 (CDA Base) - this is an illegal constraint - deleted max=* | ||
|
healthCareFacility
|
1..1 | |||
|
id
|
1..* | |||
|
component
|
1..1 | |||
|
structuredBody
|
C | 1..1 |
1198-30412:
This structuredBody **SHALL** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09), or an Assessment Section (2.16.840.1.113883.10.20.22.2.8) and a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) (CONF:1198-30412). 1198-30414: This structuredBody **SHALL NOT** contain an Assessment and Plan Section (V2) (2.16.840.1.113883.10.20.22.2.9:2014-06-09) when either an Assessment Section (2.16.840.1.113883.10.20.22.2.8) or a Plan of Treatment Section (V2) (2.16.840.1.113883.10.20.22.2.10:2014-06-09) is present (CONF:1198-30414). 1198-30415: This structuredBody **SHALL NOT** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30415). |
|
|
Slices for component
|
Slice: Unordered, Open by value:ClinicalDocument.section | |||
|
component:component1
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component2
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component3
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component4
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component5
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component6
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component7
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component8
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component9
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component10
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component11
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component12
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component13
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component14
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component15
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component16
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component17
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component18
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component19
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component20
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component21
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component22
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component23
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component24
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component25
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component26
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component27
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component28
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
Documentation for this format
|
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