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) generated with FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: Procedure Context

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/2.16.840.1.113883.10.20.6.2.5 Version: 2.1.0-draft1
Active as of 2023-01-16 Computable Name: ProcedureContext
Other Identifiers: id: urn:oid:2.16.840.1.113883.10.20.6.2.5

The ServiceEvent Procedure Context of the document header may be overridden in the CDA structured body if there is a need to refer to multiple imaging procedures or acts. The selection of the Procedure or Act entry from the clinical statement choice box depends on the nature of the imaging service that has been performed. The Procedure entry shall be used for image-guided interventions and minimally invasive imaging services, whereas the Act entry shall be used for diagnostic imaging services.

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1CDAR2.ActBase for all types and resources
81-9199: Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.2.5
... effectiveTime 0..1IVL_TS
.... value 1..1dateTime

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
81-9199warningActProcedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1CDAR2.ActBase for all types and resources
81-9199: Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.2.5
... effectiveTime 0..1IVL_TS
.... value 1..1dateTime

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Act.codeextensibleActCode

Constraints

IdGradePath(s)DetailsRequirements
81-9199warningActProcedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1CDAR2.ActBase for all types and resources
81-9199: Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.2.5
..... extension 0..1string
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 1..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 0..1TS
.... high 0..1TS
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... 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
... specimen 0..*Specimen
... performer 0..*Performer2
... 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
... participant 0..*Participant2
... entryRelationship 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
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 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..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.statusCoderequiredActStatus
Act.effectiveTime.nullFlavorrequiredNullFlavor
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
act-er-1errorAct.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
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()

This structure is derived from CDAR2.Act

Summary

Mandatory: 5 elements (1 nested mandatory element)

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the value of value:root

Differential View

This structure is derived from CDAR2.Act

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1CDAR2.ActBase for all types and resources
81-9199: Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.2.5
... effectiveTime 0..1IVL_TS
.... value 1..1dateTime

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
81-9199warningActProcedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
:

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1CDAR2.ActBase for all types and resources
81-9199: Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.2.5
... effectiveTime 0..1IVL_TS
.... value 1..1dateTime

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Act.codeextensibleActCode

Constraints

IdGradePath(s)DetailsRequirements
81-9199warningActProcedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Act C1..1CDAR2.ActBase for all types and resources
81-9199: Procedure Context SHALL be represented with the procedure or act elements depending on the nature of the procedure (CONF:81-9199).
... classCode 1..1codeRequired Pattern: ACT
... moodCode 1..1codeRequired Pattern: EVN
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:root
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.6.2.5
..... extension 0..1string
... id 0..*II
... code 1..1CDBinding: v3 Code System ActCode (extensible)
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... value 1..1dateTime
.... inclusive 0..1boolean
.... operator 0..1code
.... low 0..1TS
.... high 0..1TS
.... width 0..1PQ
.... center 0..1TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... 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
... specimen 0..*Specimen
... performer 0..*Performer2
... 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
... participant 0..*Participant2
... entryRelationship 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
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 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..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Act.templateId:primary.nullFlavorrequiredNullFlavor
Act.codeextensibleActCode
Act.statusCoderequiredActStatus
Act.effectiveTime.nullFlavorrequiredNullFlavor
Act.priorityCodeextensibleActPriority
Act.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Act.subject.typeCoderequiredFixed Value: SBJ
Act.subject.contextControlCoderequiredFixed Value: OP
Act.subject.awarenessCodeextensibleTargetAwareness
Act.informant.typeCoderequiredFixed Value: INF
Act.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
act-er-1errorAct.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
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()

This structure is derived from CDAR2.Act

Summary

Mandatory: 5 elements (1 nested mandatory element)

Slices

This structure defines the following Slices:

  • The element Act.templateId is sliced based on the value of value:root

 

​Other representations of profile: CSV, Excel, Schematron