StructureDefinition-2.16.840.1.113883.10.20.22.4.14

Sourcehl7.cda.us.ccda#current:Consolidated CDA Release 2.1 StructureDefinition Publication (v5.0.0)
resourceTypeStructureDefinition
id2.16.840.1.113883.10.20.22.4.14
canonicalhttp://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.14
version2.1
statusactive
publisherHealth Level Seven
nameProcedureActivityProcedureV3
titleProcedure Activity Procedure (V3)
date2023-08-24T14:33:15+00:00
descriptionThe 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. Procedure Activity Procedure V3 Usage Note: Common practice in the industry has shown that Procedure Activity Procedure is the usually implemented CDA template for any type of intervention or procedure regardless of if the "immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient" or not. As a result, it is recommended to use Procedure Activity Procedure when sending procedures also thought of as "interventions" such as "Home Environment Evaluation" or "Assessment of nutritional status".
jurisdictionsus
fhirVersion5.0.0
kindlogical
abstractfalse
sdTtypehttp://hl7.org/cda/stds/core/StructureDefinition/Procedure
derivationconstraint
basehttp://hl7.org/cda/stds/core/StructureDefinition/Procedure
Usages
Name Flags Card. Type Description & Constraints doco
. . Procedure CDAR2.Procedure XML Namespace: urn:hl7-org:v3
This logical model cannot be the target of a reference
. . . classCode 1..1 classCode
Fixed Value: PROC
. . . moodCode 1..1 moodCode
Fixed Value: EVN
. . . Slices for templateId 1 .. Slice: Unordered, Open by value:root, value:extension
. . . . templateId:templateId1 1..1 templateId
. . . . . root 1..1 root
Required Pattern: 2.16.840.1.113883.10.20.22.4.14
. . . . . extension 1..1 extension
Required Pattern: 2022-06-01
. . . id 1..* id
. . . code C 1..1 code
4515-19207: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
4515-32984: If the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
. . . . originalText 0..1 originalText
. . . . . reference 0..1 reference
. . . . . . value C 0..1 value
4515-19206: 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) (CONF:4515-19206).
. . . statusCode 1..1 statusCode
. . . . code 1..1 code
Binding: ProcedureAct statusCode ( required )
. . . effectiveTime 0..1 effectiveTime
. . . priorityCode 0..1 priorityCode
Binding: ActPriority ( required )
. . . methodCode C 0..1 methodCode
4515-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
. . . targetSiteCode 0..* targetSiteCode
Binding: Body Site Value Set ( required )
. . . specimen C 0..* specimen
4515-16842: This specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
. . . . specimenRole 1..1 specimenRole
. . . . . id C 0..* id
4515-29744: 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 (CONF:4515-29744).
. . . Slices for performer Slice: Unordered, Open by value:assignedEntity
. . . . performer:performer1 0..* performer
. . . . . assignedEntity 1..1 assignedEntity
. . . . . . id 1..* id
. . . . . . addr 1..* addr
. . . . . . telecom 1..* telecom
. . . . . . representedOrganization 0..1 representedOrganization
. . . . . . . id 0..* id
. . . . . . . name 0..* name
. . . . . . . telecom 1..* telecom
. . . . . . . addr 1..* addr
. . . author 0..* http://hl7.org/cda/stds/core/StructureDefinition/Author author
. . . Slices for participant Slice: Unordered, Open by value:participantRole, value:typeCode
. . . . participant:participant1 0..* participant
. . . . . typeCode 1..1 typeCode
Fixed Value: DEV
. . . . . participantRole 1..1 http://hl7.org/cda/stds/core/StructureDefinition/ParticipantRole participantRole
. . . . participant:participant2 0..* participant
. . . . . typeCode 1..1 typeCode
Fixed Value: LOC
. . . . . participantRole 1..1 http://hl7.org/cda/stds/core/StructureDefinition/ParticipantRole participantRole
. . . Slices for entryRelationship Slice: Unordered, Open by value:act, value:typeCode
. . . . entryRelationship:entryRelationship1 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: COMP
. . . . . inversionInd 1..1 inversionInd
Fixed Value: true
. . . . . encounter 1..1 encounter
. . . . . . classCode 1..1 classCode
Fixed Value: ENC
. . . . . . moodCode 1..1 moodCode
Fixed Value: EVN
. . . . . . id C 1..1 id
4515-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
. . . . entryRelationship:entryRelationship2 0..1 entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: SUBJ
. . . . . inversionInd 1..1 inversionInd
Fixed Value: true
. . . . . act 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Act act
. . . . entryRelationship:entryRelationship3 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: RSON
. . . . . observation 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Observation observation
. . . . entryRelationship:entryRelationship4 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: COMP
. . . . . substanceAdministration 1..1 http://hl7.org/cda/stds/core/StructureDefinition/SubstanceAdministration substanceAdministration
. . . . entryRelationship:entryRelationship5 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: COMP
. . . . . observation 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Observation observation
. . . . entryRelationship:entryRelationship6 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: RSON
. . . . . observation 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Observation observation
. . . . entryRelationship:entryRelationship7 0..* entryRelationship
. . . . . typeCode 1..1 typeCode
Fixed Value: RSON
. . . . . act 1..1 http://hl7.org/cda/stds/core/StructureDefinition/Act act

doco Documentation for this format

Produced 08 Sep 2023