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Template 1.3.6.1.4.1.19376.1.5.3.1.4.19 - EntryProcedure
Id 1.3.6.1.4.1.19376.1.5.3.1.4.19
Version valid from 2013‑12‑20 status draft Under develeopment
Classification CDA Entry Level Template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.19
Open/Closed Open (other than defined elements are allowed)
Description

The procedure entry is used to record procedures that have occured, or which are planned for in the future.

Used by / Uses
Used by / Uses 7 templates
Used by Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.3.12 Containment SectionCodedListOfSurgeries Section Coded List of Surgeries 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link epSOS-PS epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link epSOS-HCER epSOS-Health Care Encounter Report 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.28 Containment SectionCodedResults Section Coded Results 2013‑12‑20
Uses Template id as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.4.1 Containment EntryInternalReference DYNAMIC
Example
Patient had an operation on his urinary system in Feb, 2011
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
  <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>
  <effectiveTime value="201102"/>
</procedure>
Item DT Card Conf Description Label
hl7:procedure
R

The templateId indicates that this <procedure> entry conforms to the constraints of this content module. NOTE: When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29, and when in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

(EntryProcedure)
treetree @classCode
1 .. 1 F PROC
treetree @moodCode
1 .. 1 R
  CONF
@moodCode shall be "EVN"
or
@moodCode shall be "INT"
  Example <procedure classCode="PROC" moodCode="EVN|INT">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
  <templateId root="2.16.840.1.113883.10.20.1.29"/>
  <!-- see text of section 0 -->
  <templateId root="2.16.840.1.113883.10.20.1.25"/>
  <!-- see text of section 0 -->
  <id root="" extension=""/>
  <code code="" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
  <text>
    <reference value="#xxx"/>
  </text>  <statusCode code="completed|active|aborted|cancelled"/>
  <effectiveTime>
    <low value=""/>
    <high value=""/>
  </effectiveTime>  <priorityCode code=""/>
  <approachSiteCode code="" displayName="" codeSystem="" codeSystemName=""/>
  <targetSiteCode code="" displayName="" codeSystem="" codeSystemName=""/>
  <author/>
  <informant/>
  <entryRelationship typeCode="COMP" inversionInd="true">
    <act classCode="ACT" moodCode="">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/>
      <id root="" extension=""/>
    </act>  </entryRelationship>  <entryRelationship typeCode="RSON">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/>
      <id root="" extension=""/>
    </act>  </entryRelationship></procedure>
treetree hl7:templateId
II.EPSOS 1 .. 1 M (EntryProcedure)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.19
treetree hl7:templateId
II.EPSOS 1 .. 1 R (EntryProcedure)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.29
treetree hl7:templateId
II.EPSOS 1 .. 1 R (EntryProcedure)
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.1.25
treetree hl7:id
II.EPSOS 1 .. * R This required element shall contain an identifier for the procedure. More than one procedure identi-fier may be present. (EntryProcedure)
treetree hl7:code
CD.EPSOS 1 .. 1 R Procedure Id Code. This element shall be present and should contain a code describing the type of procedure. R9.2
treeblank treetree @displayName
0 .. 1  
  Procedure description
treeblank treetree @nullFlavor
0 .. 1  
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.10 epSOSProcedures (DYNAMIC)
  Example <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>
treetree hl7:text
ED 1 .. 1 R Description of procedures (EntryProcedure)
  Example <text>Operation on urinary system</text>
treetree hl7:statusCode
CS 1 .. 1 R This element shall be present when used to describe a procedure event. It shall have the value 'completed' for procedures that have been completed and 'active' for procedures that are still in progress. Procedures that were stopped prior to completion shall use the value 'aborted', and procedures that were cancelled before being started shall use the value 'cancelled'. (EntryProcedure)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.159331 ActStatus (DYNAMIC)
treetree hl7:effectiveTime
IVL_TS 1 .. 1 R Procedure Date. This element should be present, and records the time at which the procedure occurred (in EVN mood), or the desired time of the procedure in INT mood. R9.3
treetree hl7:priorityCode
CE.EPSOS 1 .. 1 R This element shall be present in INT mood when effectiveTime is not provided, it may be present in 2550 other moods. It indicates the priority of the procedure. (EntryProcedure)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
treetree hl7:approachSiteCode
CD.EPSOS 0 .. 1 R This element may be present to indicate the procedure approach. (EntryProcedure)
treeblank treetree @codeSystem
1 .. 1 F 2.16.840.1.113883.5.1052 (ActSite)
  Example <code code="RLAQ" codeSystem="2.16.840.1.113883.5.1052" codeSystemName="ActSite" displayName="right lower abd quadrant"/>
treetree hl7:targetSiteCode
CD.EPSOS 0 .. * R This element may be present to indicate the target site of the procedure. (EntryProcedure)
  Example <targetSiteCode code="76552005" codeSystem="2.16.840.1.113883.6.96" displayName="skin structure of shoulder">
  <qualifier>
    <name code="272741003" displayName="Laterality"/>
    <value code="7771000" displayName="Left"/>
  </qualifier></targetSiteCode>
treetree hl7:entryRelationship
where
[hl7:act [hl7:templateId/@root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1']]
0 .. * R

This element may be present to point the encounter in which the procedure was performed, and shall contain an internal reference to the encounter.

A <procedure> act may indicate one or more reasons for the procedure. These reasons identify the concern that was the reason for the procedure via an Internal Reference to the concern. The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.

(EntryProcedure)
treeblank treetree @inversionInd
bl 0 .. 1  
  Contains 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 Internal Reference (DYNAMIC)