Consolidated CDA Release 2.1 StructureDefinition Prototype Publication
2.1.0-draft1 - CI Build
United States of America
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 
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.41 | Version: 2.1.0-draft1 | |||
| Active as of 2023-01-16 | Computable Name: PlannedProcedure | |||
| Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09 | ||||
This template represents planned alterations of the patient’s physical condition. Examples of such procedures are tracheostomy, knee replacement, and craniectomy. The priority of the procedure to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the procedure is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Procedure Template may also indicate the potential insurance coverage for the procedure.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 1..1 | CDAR2.Procedure | Base for all types and resources | |
  classCode | 1..1 | code | Required Pattern: PROC | |
| moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
  extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). |
| statusCode | 1..1 | CS | ||
 code | 1..1 | string | Required Pattern: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
| methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
| author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
 Slices for entryRelationship | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act | |
 entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |
 typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | 0..* | Element | The following entryRelationship represents the indication for the procedure. | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
| Procedure.targetSiteCode | required | Body Site Value Set |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). : |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 1..1 | CDAR2.Procedure | Base for all types and resources | |
 classCode | 1..1 | code | Binding: ActClassProcedure (required) Fixed Value: PROC | |
| moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
| methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
| author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
| Slices for entryRelationship | C | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act |
| entryRelationship:All Slices | Content/Rules for all slices | |||
 typeCode | 1..1 | code | ||
 contextConductionInd | 1..1 | boolean | ||
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | C | 0..* | Element | The following entryRelationship represents the indication for the procedure. |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | C | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
| Procedure.statusCode | required | ActStatus |
| Procedure.targetSiteCode | required | Body Site Value Set |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| proc-er-1 | error | Procedure.entryRelationship, Procedure.entryRelationship:priorityPreference, Procedure.entryRelationship:indication, Procedure.entryRelationship:instruction, Procedure.entryRelationship:plannedCoverage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 1..1 | CDAR2.Procedure | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassProcedure (required) Fixed Value: PROC | |
| moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). |
| negationInd | 0..1 | boolean | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: active | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
| approachSiteCode | 0..* | CD | ||
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
 subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
| author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
 (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | C | 0..* | Element | The following entryRelationship represents the indication for the procedure. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | C | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 0..1 | ExternalDocument | ||
| precondition | 0..* | Precondition | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
| Procedure.templateId:primary.nullFlavor | required | NullFlavor |
| Procedure.statusCode | required | ActStatus |
| Procedure.statusCode.nullFlavor | required | NullFlavor |
| Procedure.priorityCode | extensible | ActPriority |
| Procedure.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Procedure.targetSiteCode | required | Body Site Value Set |
| Procedure.subject.typeCode | required | Fixed Value: SBJ |
| Procedure.subject.contextControlCode | required | Fixed Value: OP |
| Procedure.subject.awarenessCode | extensible | TargetAwareness |
| Procedure.informant.typeCode | required | Fixed Value: INF |
| Procedure.informant.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| proc-er-1 | error | Procedure.entryRelationship, Procedure.entryRelationship:priorityPreference, Procedure.entryRelationship:indication, Procedure.entryRelationship:instruction, Procedure.entryRelationship:plannedCoverage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
This structure is derived from CDAR2.Procedure
Summary
Mandatory: 9 elements (9 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 1..1 | CDAR2.Procedure | Base for all types and resources | |
| classCode | 1..1 | code | Required Pattern: PROC | |
| moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Required Pattern: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
| methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
| author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
| Slices for entryRelationship | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act | |
| entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | 0..* | Element | The following entryRelationship represents the indication for the procedure. | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
| Procedure.targetSiteCode | required | Body Site Value Set |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). : |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 1..1 | CDAR2.Procedure | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassProcedure (required) Fixed Value: PROC | |
| moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). |
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| code | 1..1 | string | Required Pattern: active | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
| methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
| performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
| author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
| Slices for entryRelationship | C | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| typeCode | 1..1 | code | ||
| contextConductionInd | 1..1 | boolean | ||
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | C | 0..* | Element | The following entryRelationship represents the indication for the procedure. |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| contextConductionInd | 1..1 | boolean | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | C | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | C | 0..* | Element | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| contextConductionInd | 1..1 | boolean | ||
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
| Procedure.statusCode | required | ActStatus |
| Procedure.targetSiteCode | required | Body Site Value Set |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| proc-er-1 | error | Procedure.entryRelationship, Procedure.entryRelationship:priorityPreference, Procedure.entryRelationship:indication, Procedure.entryRelationship:instruction, Procedure.entryRelationship:plannedCoverage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 1..1 | CDAR2.Procedure | Base for all types and resources | |
| classCode | 1..1 | code | Binding: ActClassProcedure (required) Fixed Value: PROC | |
| moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
| realmCode | 0..* | CS | ||
| typeId | 0..1 | II | ||
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| assigningAuthorityName | 0..1 | string | ||
| displayable | 0..1 | boolean | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | C | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). |
| negationInd | 0..1 | boolean | ||
| text | 0..1 | ED | ||
| statusCode | 1..1 | CS | Binding: ActStatus (required) | |
| nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
| code | 1..1 | string | Required Pattern: active | |
| sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
| sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
| effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
| priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
| languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
| methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
| approachSiteCode | 0..* | CD | ||
| targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
| subject | 0..1 | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
| relatedSubject | 1..1 | RelatedSubject | ||
| specimen | 0..* | Specimen | ||
| performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
| author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
| informant | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
| contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
| assignedEntity | 0..1 | AssignedEntity | ||
| relatedEntity | 0..1 | RelatedEntity | ||
| participant | 0..* | Participant2 | ||
| Slices for entryRelationship | C | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act |
| entryRelationship:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| (Choice of one) | 1..1 | |||
| observation | 0..1 | Observation | ||
| regionOfInterest | 0..1 | RegionOfInterest | ||
| observationMedia | 0..1 | ObservationMedia | ||
| substanceAdministration | 0..1 | SubstanceAdministration | ||
| supply | 0..1 | Supply | ||
| procedure | 0..1 | Procedure | ||
| encounter | 0..1 | Encounter | ||
| organizer | 0..1 | Organizer | ||
| act | 0..1 | Act | ||
| entryRelationship:priorityPreference | C | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: REFR | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | PriorityPreference | Base for all types and resources | |
| entryRelationship:indication | C | 0..* | Element | The following entryRelationship represents the indication for the procedure. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: RSON | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| observation | 1..1 | Indication | Base for all types and resources | |
| entryRelationship:instruction | C | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | Instruction | Base for all types and resources | |
| entryRelationship:plannedCoverage | C | 0..* | Element | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 0..1 | boolean | ||
| contextConductionInd | 1..1 | boolean | ||
| sequenceNumber | 0..1 | INT | ||
| negationInd | 0..1 | boolean | ||
| seperatableInd | 0..1 | BL | ||
| act | 1..1 | PlannedCoverage | Base for all types and resources | |
| reference | 0..* | Element | ||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
| typeCode | 1..1 | code | ||
| seperatableInd | 0..1 | BL | ||
| externalAct | 0..1 | ExternalAct | ||
| externalObservation | 0..1 | ExternalObservation | ||
| externalProcedure | 0..1 | ExternalProcedure | ||
| externalDocument | 0..1 | ExternalDocument | ||
| precondition | 0..* | Precondition | ||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
| Procedure.templateId:primary.nullFlavor | required | NullFlavor |
| Procedure.statusCode | required | ActStatus |
| Procedure.statusCode.nullFlavor | required | NullFlavor |
| Procedure.priorityCode | extensible | ActPriority |
| Procedure.languageCode | required | HumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066) |
| Procedure.targetSiteCode | required | Body Site Value Set |
| Procedure.subject.typeCode | required | Fixed Value: SBJ |
| Procedure.subject.contextControlCode | required | Fixed Value: OP |
| Procedure.subject.awarenessCode | extensible | TargetAwareness |
| Procedure.informant.typeCode | required | Fixed Value: INF |
| Procedure.informant.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path(s) | Details | Requirements |
| 1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **SHOULD** be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) *OR* SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) **OR** ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) (CONF:1098-31977). : | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| proc-er-1 | error | Procedure.entryRelationship, Procedure.entryRelationship:priorityPreference, Procedure.entryRelationship:indication, Procedure.entryRelationship:instruction, Procedure.entryRelationship:plannedCoverage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
This structure is derived from CDAR2.Procedure
Summary
Mandatory: 9 elements (9 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#2.1.0-draft1 based on FHIR 5.0.0-snapshot3. Generated 2023-01-16
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