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ref Template  Procedure

Id 1.3.6.1.4.1.19376.1.5.3.1.4.19 Effective Date valid from 2013‑12‑20
Status draft Draft Version Label
Name EntryProcedure Display Name Procedure
Description

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

In case no procedures are expected to be recorded, a single “NA” nullFlavored procedure entry shall be included in this section.
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.19
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 3 concepts
Id Name Data Set
epsos-dataelement-3 Procedure description epSOS Data Set
epsos-dataelement-2 Procedure Id (code) epSOS Data Set
epsos-dataelement-4 Procedure Date epSOS Data Set
Used by / Uses
Used by 0 transactions and 4 templates, Uses 1 template
Used by as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Containment draft Section Coded Results 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link draft epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.12 Containment draft Section Coded List of Surgeries 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link draft epSOS-Health Care Encounter Report 2013‑12‑20
Uses as Name Version
1.3.6.1.4.1.19376.1.5.3.1.4.4.1 Containment draft Internal Reference DYNAMIC
Example
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 -->
  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <!-- see text of section -->
  <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>
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"/>  <id nullFlavor="NA"/>  <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>  <statusCode code="completed"/>  <effectiveTime value="201102"/></procedure>
Example
Patient had no procedures to be recorded
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>  <id nullFlavor="NA"/>  <code nullFlavor="NA"/>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA"/></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.

(Ent…ure)
@classCode
 cs 1 … 1 F PROC
@moodCode
 cs 1 … 1 R
  CONF
@moodCode shall be "EVN"
or
@moodCode shall be "INT"
hl7:templateId
 II.EPSOS 1 … 1 M (Ent…ure)
@root
 uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.19
Choice  … 1 Elements to choose from:
  • hl7:templateId[@root='2.16.840.1.113883.10.20.1.29']
  • hl7:templateId[@root='2.16.840.1.113883.10.20.1.25']
hl7:templateId
 II.EPSOS 0 … 1 C 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 (Ent…ure)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.29
hl7:templateId
 II.EPSOS 0 … 1 C When the procedure is in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25. (Ent…ure)
@root
 uid 1 … 1 F 2.16.840.1.113883.10.20.1.25
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. (Ent…ure)
hl7:code
 CE.EPSOS 1 … 1 R Procedure Id Code. This element shall be present and should contain a code describing the type of procedure. R9.2
  target
epsos-dataelement-2 Procedure Id (code) epSOS Data Set
@displayName
 0 … 1   Procedure description R9.1
@nullFlavor
 cs 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"/>
hl7:text
 ED 1 … 1 R Description of procedures (Ent…ure)
  target
epsos-dataelement-3 Procedure description epSOS Data Set
hl7:reference
 TEL 1 … 1 M (Ent…ure)
@value
 1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
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'. (Ent…ure)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.777.11.11.3 ActStatusActiveAbortedCancelledCompleted (DYNAMIC)
hl7:effectiveTime
 IVL_TS 1 … 1 R IHE-PCC: 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.
epSOS: Procedure date is required. 		R9.3
  target
epsos-dataelement-4 Procedure Date epSOS Data Set
hl7:priorityCode
 CE.EPSOS 0 … 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. (Ent…ure)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
hl7:approachSiteCode
 CD.EPSOS 0 … 1 R This element may be present to indicate the procedure approach. (Ent…ure)
@codeSystem
 CONF 0 … 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"/>
hl7:targetSiteCode
 CD.EPSOS 0 … * R This element may be present to indicate the target site of the procedure. (Ent…ure)
  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>
hl7:entryRelationship
 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.


Contains 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 Internal Reference (DYNAMIC) 		(Ent…ure)
treeblank where [hl7:act [hl7:templateId [@root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1']]]
@inversionInd
 bl 0 … 1