Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build United States of America

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) based on FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Procedures Section - entries required

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.7.1 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: ProceduresSectionentriesrequired
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09

This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of “procedure” is broader than that specified by the HL7 Version 3 Reference Information Model (RIM), therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures that alter the physical condition of a patient (e.g., splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Act is for all other types of procedures (e.g., dressing change).

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ProceduresSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... entry 1..*ElementIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12:2014-06-09) OR Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13:2014-06-09) OR Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CEBinding: DocumentSectionType (extensible)
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C1..*ElementIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12:2014-06-09) OR Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13:2014-06-09) OR Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources
.... entry:entryAct C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1ProcedureActivityActBase for all types and resources
.... entry:entryObservation C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1ProcedureActivityObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
only-one-statementerrorSection.entry, Section.entry:entryProcedure, Section.entry:entryAct, Section.entry:entryObservationSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry C1..*ElementIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12:2014-06-09) OR Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13:2014-06-09) OR Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources
.... entry:entryAct C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1ProcedureActivityActBase for all types and resources
.... entry:entryObservation C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1ProcedureActivityObservationBase for all types and resources
... component 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
only-one-statementerrorSection.entry, Section.entry:entryProcedure, Section.entry:entryAct, Section.entry:entryObservationSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from ProceduresSectionEntriesOptional

Summary

Mandatory: 9 elements

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension

Differential View

This structure is derived from ProceduresSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... entry 1..*ElementIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12:2014-06-09) OR Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13:2014-06-09) OR Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... moodCode 1..1codeBinding: ActMood (required)
Fixed Value: EVN
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CEBinding: DocumentSectionType (extensible)
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... title 1..1ED
... text S1..1xhtml
... Slices for entry C1..*ElementIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12:2014-06-09) OR Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13:2014-06-09) OR Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources
.... entry:entryAct C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1ProcedureActivityActBase for all types and resources
.... entry:entryObservation C0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1ProcedureActivityObservationBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
only-one-statementerrorSection.entry, Section.entry:entryProcedure, Section.entry:entryAct, Section.entry:entryObservationSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptionalBase for all types and resources
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1codeBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry C1..*ElementIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Act (V2) (templateId 2.16.840.1.113883.10.20.22.4.12:2014-06-09) OR Procedure Activity Observation (V2) (templateId: 2.16.840.1.113883.10.20.22.4.13:2014-06-09) OR Procedure Activity Procedure (V2) (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources
.... entry:entryAct C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1ProcedureActivityActBase for all types and resources
.... entry:entryObservation C0..*Element
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1ProcedureActivityObservationBase for all types and resources
... component 0..*Element
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
only-one-statementerrorSection.entry, Section.entry:entryProcedure, Section.entry:entryAct, Section.entry:entryObservationSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from ProceduresSectionEntriesOptional

Summary

Mandatory: 9 elements

Slices

This structure defines the following Slices:

  • The element Section.templateId is sliced based on the values of value:root, value:extension

 

​Other representations of profile: CSV, Excel, Schematron