Procedure (CDA Class) - Definitions - Clinical Document Architecture v2.0.0-sd

This page is part of the CDA: Clinical Document Architecture (v2.0.0-sd: CDA2 - Informative) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions

Logical Model: Procedure - Detailed Descriptions

Active as of 2024-05-17

Definitions for the Procedure logical model.

Differential Elements Table
Key Elements Table
Snapshot Elements Table

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Control	1..1
Logical Container	ClinicalDocument (CDA Class)
Validation	Instance of this type are validated by templateId
XML Format	In the XML format, this property has the namespace `urn:hl7-org:v3`.
2. Procedure.classCode
Control	1..1
Binding	The codes SHALL be taken from ActClassProcedure (required to `http://terminology.hl7.org/ValueSet/v3-ActClassProcedure`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Fixed Value	`PROC`
4. Procedure.moodCode
Control	1..1
Binding	The codes SHALL be taken from x_DocumentProcedureMood (required to `http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
6. Procedure.id
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/II
8. Procedure.code
Definition	Drawn from concept domain ActCode
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
10. Procedure.negationInd
Control	0..1
Type	boolean(bl: Boolean)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
12. Procedure.text
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/ED
14. Procedure.statusCode
Control	0..1
Binding	The codes SHALL be taken from ActStatus (required to `http://terminology.hl7.org/ValueSet/v3-ActStatus`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
16. Procedure.effectiveTime
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
18. Procedure.priorityCode
Control	0..1
Binding	For example codes, see ActPriority (example to `http://terminology.hl7.org/ValueSet/v3-ActPriority`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CE
20. Procedure.languageCode
Control	0..1
Binding	The codes SHALL be taken from AllLanguages (required to `http://hl7.org/fhir/ValueSet/all-languages`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
22. Procedure.methodCode
Definition	Drawn from concept domain ProcedureMethod
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CE
24. Procedure.approachSiteCode
Definition	Drawn from concept domain ActSite
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
26. Procedure.targetSiteCode
Definition	Drawn from concept domain ActSite
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
28. Procedure.subject
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/Subject
30. Procedure.specimen
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Specimen
32. Procedure.performer
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Performer2
34. Procedure.author
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Author
36. Procedure.informant
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Informant
38. Procedure.participant
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Participant2
40. Procedure.entryRelationship
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
42. Procedure.reference
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Reference
44. Procedure.precondition
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Precondition
46. Procedure.sdtcPrecondition2
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Precondition2
XML Format	In the XML format, this property has the namespace `urn:hl7-org:sdtc`.In the XML format, this property has the actual name`precondition2`.
48. Procedure.sdtcInFulfillmentOf1
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf1
XML Format	In the XML format, this property has the namespace `urn:hl7-org:sdtc`.In the XML format, this property has the actual name`inFulfillmentOf1`.

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Definition	Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type. Base definition for all types defined in FHIR type system.
Short	Base for all types and resources
Control	10..1*
Is Modifier	false
Logical Container	ClinicalDocument (CDA Class)
Validation	Instance of this type are validated by templateId
XML Format	In the XML format, this property has the namespace `urn:hl7-org:v3`.
2. Procedure.classCode
Control	1..1
Binding	The codes SHALL be taken from ActClassProcedure (required to `http://terminology.hl7.org/ValueSet/v3-ActClassProcedure`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Fixed Value	`PROC`
4. Procedure.moodCode
Control	1..1
Binding	The codes SHALL be taken from x_DocumentProcedureMood (required to `http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
6. Procedure.id
Definition	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short	Logical id of this artifact
Comments	Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.
Control	0..*1
Type	http://hl7.org/cda/stds/core/StructureDefinition/IIid
Is Modifier	false
8. Procedure.code
Definition	Drawn from concept domain ActCode The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
Short	Identification of the procedure
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/CDCodeableConcept
Is Modifier	false
Requirements	0..1 to account for primarily narrative only resources.
Alternate Names	type
Invariants	ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Procedure.negationInd
Control	0..1
Type	boolean(bl: Boolean)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
12. Procedure.text
Definition	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short	Text summary of the resource, for human interpretation
Comments	Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control	0..1 This element is affected by the following invariants: dom-6
Type	http://hl7.org/cda/stds/core/StructureDefinition/EDNarrative
Is Modifier	false
Alternate Names	narrative, html, xhtml, display
Invariants	ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. Procedure.statusCode
Control	0..1
Binding	The codes SHALL be taken from ActStatus (required to `http://terminology.hl7.org/ValueSet/v3-ActStatus`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
16. Procedure.effectiveTime
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
18. Procedure.priorityCode
Control	0..1
Binding	For example codes, see ActPriority (example to `http://terminology.hl7.org/ValueSet/v3-ActPriority`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CE
20. Procedure.languageCode
Control	0..1
Binding	The codes SHALL be taken from AllLanguages (required to `http://hl7.org/fhir/ValueSet/all-languages`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
22. Procedure.methodCode
Definition	Drawn from concept domain ProcedureMethod
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CE
24. Procedure.approachSiteCode
Definition	Drawn from concept domain ActSite
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
26. Procedure.targetSiteCode
Definition	Drawn from concept domain ActSite
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
28. Procedure.subject
Definition	On whom or on what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure.
Short	Individual or entity the procedure was performed on
Control	01..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/SubjectReference(Patient, Group, Device, Practitioner, Organization, Location)
Is Modifier	false
Alternate Names	patient
Invariants	ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Procedure.specimen
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Specimen
32. Procedure.performer
Definition	Indicates who or what performed the procedure and how they were involved.
Short	Who performed the procedure and what they did
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Performer2BackboneElement
Is Modifier	false
Invariants	ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) prc-1: Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole (onBehalfOf.exists() and actor.resolve().exists() implies actor.resolve().where($this is Practitioner or $this is PractitionerRole).empty())
34. Procedure.author
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Author
36. Procedure.informant
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Informant
38. Procedure.participant
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Participant2
40. Procedure.entryRelationship
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
42. Procedure.reference
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Reference
44. Procedure.precondition
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Precondition
46. Procedure.sdtcPrecondition2
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Precondition2
XML Format	In the XML format, this property has the namespace `urn:hl7-org:sdtc`.In the XML format, this property has the actual name`precondition2`.
48. Procedure.sdtcInFulfillmentOf1
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf1
XML Format	In the XML format, this property has the namespace `urn:hl7-org:sdtc`.In the XML format, this property has the actual name`inFulfillmentOf1`.

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Definition	Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.
Short	Base for all types and resources
Control	1..1
Is Modifier	false
Logical Container	ClinicalDocument (CDA Class)
Validation	Instance of this type are validated by templateId
XML Format	In the XML format, this property has the namespace `urn:hl7-org:v3`.
2. Procedure.nullFlavor
Definition	If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
Control	0..1
Binding	The codes SHALL be taken from CDANullFlavor (required to `http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Label	Exceptional Value Detail
4. Procedure.realmCode
Definition	When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
6. Procedure.typeId
Definition	When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/II
8. Procedure.typeId.nullFlavor
Definition	If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
Control	0..1
Binding	The codes SHALL be taken from CDANullFlavor (required to `http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Label	Exceptional Value Detail
10. Procedure.typeId.assigningAuthorityName
Definition	A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Control	0..1
Type	string(st: Character String)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Label	Assigning Authority Name
12. Procedure.typeId.displayable
Definition	Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Control	0..1
Type	boolean(bl: Boolean)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Label	Displayable
14. Procedure.typeId.root
Definition	Identifies the type as an HL7 Registered model
Control	1..1
Type	string(oid: ISO Object Identifier, uuid: DCE Universal Unique Identifier, ruid: HL7 Reserved Identifier Scheme)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Label	Root
Fixed Value	`2.16.840.1.113883.1.3`
16. Procedure.typeId.extension
Definition	A character string as a unique identifier within the scope of the identifier root.
Control	1..1
Type	string(st: Character String)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Label	Extension
18. Procedure.templateId
Definition	When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/II
20. Procedure.classCode
Control	1..1
Binding	The codes SHALL be taken from ActClassProcedure (required to `http://terminology.hl7.org/ValueSet/v3-ActClassProcedure`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
Fixed Value	`PROC`
22. Procedure.moodCode
Control	1..1
Binding	The codes SHALL be taken from x_DocumentProcedureMood (required to `http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood`)
Type	code(cs: Coded Simple Value)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
24. Procedure.id
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/II
26. Procedure.code
Definition	Drawn from concept domain ActCode
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
28. Procedure.negationInd
Control	0..1
Type	boolean(bl: Boolean)
Primitive Value	This primitive element may be present, or absent, or replaced by an extension
XML Format	In the XML format, this property is represented as an attribute.
30. Procedure.text
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/ED
32. Procedure.statusCode
Control	0..1
Binding	The codes SHALL be taken from ActStatus (required to `http://terminology.hl7.org/ValueSet/v3-ActStatus`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
34. Procedure.effectiveTime
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS
36. Procedure.priorityCode
Control	0..1
Binding	For example codes, see ActPriority (example to `http://terminology.hl7.org/ValueSet/v3-ActPriority`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CE
38. Procedure.languageCode
Control	0..1
Binding	The codes SHALL be taken from AllLanguages (required to `http://hl7.org/fhir/ValueSet/all-languages`)
Type	http://hl7.org/cda/stds/core/StructureDefinition/CS
40. Procedure.methodCode
Definition	Drawn from concept domain ProcedureMethod
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CE
42. Procedure.approachSiteCode
Definition	Drawn from concept domain ActSite
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
44. Procedure.targetSiteCode
Definition	Drawn from concept domain ActSite
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/CD
46. Procedure.subject
Control	0..1
Type	http://hl7.org/cda/stds/core/StructureDefinition/Subject
48. Procedure.specimen
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Specimen
50. Procedure.performer
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Performer2
52. Procedure.author
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Author
54. Procedure.informant
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Informant
56. Procedure.participant
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Participant2
58. Procedure.entryRelationship
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/EntryRelationship
60. Procedure.reference
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Reference
62. Procedure.precondition
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Precondition
64. Procedure.sdtcPrecondition2
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/Precondition2
XML Format	In the XML format, this property has the namespace `urn:hl7-org:sdtc`.In the XML format, this property has the actual name`precondition2`.
66. Procedure.sdtcInFulfillmentOf1
Control	0..*
Type	http://hl7.org/cda/stds/core/StructureDefinition/InFulfillmentOf1
XML Format	In the XML format, this property has the namespace `urn:hl7-org:sdtc`.In the XML format, this property has the actual name`inFulfillmentOf1`.