StructureDefinition-Procedure-Note

Sourcehl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1)
resourceTypeStructureDefinition
idProcedure-Note
canonicalhttp://hl7.org/fhir/us/ccda/StructureDefinition/Procedure-Note
version1.2.0-ballot
statusactive
publisherHL7 Structured Documents Working Group
nameProcedureNote
titleProcedure Note
date2023-03-27T20:25:00+00:00
descriptionA Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
Usages
Name Flags Card. Type Description & Constraints doco
. . Composition USRealmHeader
. . . type S Procedure Note
Binding: ProcedureNoteDocumentTypeCodes ( required )
. . . event S 1.. serviceEvent
. . . . period 1.. period
. . . . . start 1.. start
. . . . . end 1.. end
. . . Slices for section Slice: Unordered, Open by value:code
. . . . section:complications_section S 1..1 Complications Section
. . . . . title S 1.. title
. . . . . code S 1.. Complications
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 55109-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:complications_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:procedure_description_section S 1..1 Procedure Description Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure description
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29554-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_indications_section S 1..1 Procedure Indications Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure indications
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59768-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:postprocedure_diagnosis_section S 1..1 Postprocedure Diagnosis Section
. . . . . title S 1.. title
. . . . . code S 1.. Postprocedure diagnosis
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59769-0
. . . . . text S 1.. text
. . . . . Slices for entry S entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:postprocedure_diagnosis_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:allergies_and_intolerances_section S ..1 Allergies and Intolerances Section
. . . . . title S 1.. title
. . . . . code S 1.. Allergies and/or adverse reactions
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 48765-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:allergies_and_intolerances_entry S Reference (US Core AllergyIntolerance Profile)
. . . . section:assessment_section S ..1 Assessment Section
. . . . . title S 1.. title
. . . . . code S 1.. Assessments
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51848-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:assessment_and_plan_section S ..1 Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
. . . . . title S 1.. title
. . . . . code S 1.. Assessment and plan
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 51847-2
. . . . . text S 1.. text
. . . . . Slices for entry Slice: Unordered, Open by profile:resolve()
. . . . . . entry:assessment_and_plan_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition | Observation | Communication ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:anesthesia_section S ..1 Anesthesia Section
. . . . . title S 1.. title
. . . . . code S 1.. Anesthesia
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59774-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:anesthesia_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)
. . . . section:chief_complaint_and_reason_for_visit_section S ..1 Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 46239-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:chief_complaint_section S ..1 Chief Complaint Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10154-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:family_history_section S ..1 Family History Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10157-6
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:family_history_entry S Reference ( FamilyMemberHistory ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:past_medical_history_section S ..1 Past Medical History Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11348-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:past_medical_history_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:history_of_present_illness_section S ..1 History of Present Illness Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10164-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:medical_history_section S ..1 Medical (General) History Section
. . . . . title S 1.. title
. . . . . code S 1.. Medical (general) history
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11329-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:medications_section S ..1 Medications Section
. . . . . title S 1.. title
. . . . . code S 1.. History of medication use
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10160-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medications_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:medications_administered_section S ..1 Medications Administered Section
. . . . . title S 1.. title
. . . . . code S 1.. Medications administered
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29549-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:medications_administered_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile)
. . . . section:physical_exam_section S ..1 Physical Exam Section
. . . . . title S 1.. title
. . . . . code S 1.. Physical findings
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29545-1
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:physical_exam_entry S Reference ( Observation ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:plan_of_treatment_section S ..1 Plan of Treatment Section
. . . . . title S 1.. title
. . . . . code S 1.. Plan of treatment
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:planned_procedure_section S ..1 Planned Procedure Section
. . . . . title S 1.. title
. . . . . code S 1.. Planned procedure
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59772-4
. . . . . text S 1.. text
. . . . section:procedure_disposition_section S ..1 Procedure Disposition Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure disposition
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59775-7
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_estimated_blood_loss_section S ..1 Procedure Estimated Blood Loss Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure estimated blood loss
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59770-8
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_findings_section S ..1 Procedure Findings Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure findings
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59776-5
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_implants_section S ..1 Procedure Implants Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure implants
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59771-6
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_specimens_taken_section S ..1 Procedure Specimens Taken Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure specimens taken
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59773-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedures_section S ..1 Procedures Section
. . . . . title S 1.. title
. . . . . code S 1.. History of procedures
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 47519-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedures_entry S Reference (US Core Procedure Profile)
. . . . section:reason_for_visit_section S ..1 Reason for Visit Section
. . . . . title S 1.. title
. . . . . code S 1.. code
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29299-5
. . . . . text S 1.. This section contains only human readable content
. . . . section:review_of_systems_section S ..1 Review of Systems Section
. . . . . title S 1.. title
. . . . . code S 1.. Review of systems
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10187-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:social_history_section S ..1 Social History Section
. . . . . title S 1.. title
. . . . . code S 1.. Social history
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29762-2
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:social_history_entry S Reference (US Core Smoking Status Observation Profile) Smoking status

doco Documentation for this format

Produced 06 Apr 2023