Consolidated CDA
3.0.0-ballot - ballot United States of America flag

This page is part of the CCDA: Consolidated CDA Release (v3.0.0-ballot: CCDA 3.0 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions

Logical Model: Procedures Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: ProceduresSection
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09

This section describes all historical or current interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient 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.

Subsections MAY be used to partition the entries into different categories. For example, a subsection with the Loinc code of 18748-4 (Diagnostic Imaging) MAY be used to group DI procedures. Similarly 11502-2 (Clinical Laboratory) MAY be used to group laboratory procedures.

Usage:

Formal Views of Profile Content

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

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-procedure-act-procedure: SHALL contain at least one Procedure Activity Procedure
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of Procedures
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-procedure-act-procedureerrorSectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-procedure-act-procedure: SHALL contain at least one Procedure Activity Procedure
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of Procedures
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure C1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
active-high-ts-after-documenterrorSection.entry:entryProcedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
shall-procedure-act-procedureerrorSectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
should-authorwarningSection.entry:entryProcedure.procedureSHOULD contain author
: author.exists()
should-performerwarningSection.entry:entryProcedure.procedureSHOULD contain performer
: performer.exists()
should-targetSiteCodewarningSection.entry:entryProcedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:entryProcedure.procedureSHOULD contain text/reference/@value
: text.reference.value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-procedure-act-procedure: SHALL contain at least one Procedure Activity Procedure
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEHistory of Procedures
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure C1..1ProcedureActivityProcedureBase for all types and resources
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:entryProcedure.nullFlavorrequiredCDANullFlavor
Section.entry:entryProcedure.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:entryProcedure.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
active-high-ts-after-documenterrorSection.entry:entryProcedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
shall-procedure-act-procedureerrorSectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
should-authorwarningSection.entry:entryProcedure.procedureSHOULD contain author
: author.exists()
should-performerwarningSection.entry:entryProcedure.procedureSHOULD contain performer
: performer.exists()
should-targetSiteCodewarningSection.entry:entryProcedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:entryProcedure.procedureSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-procedure-act-procedure: SHALL contain at least one Procedure Activity Procedure
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of Procedures
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
shall-procedure-act-procedureerrorSectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-procedure-act-procedure: SHALL contain at least one Procedure Activity Procedure
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:section 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEHistory of Procedures
Binding: DocumentSectionType (example)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 0..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure C1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Section.nullFlavorrequiredCDANullFlavor
Section.codeexampleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
active-high-ts-after-documenterrorSection.entry:entryProcedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
shall-procedure-act-procedureerrorSectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
should-authorwarningSection.entry:entryProcedure.procedureSHOULD contain author
: author.exists()
should-performerwarningSection.entry:entryProcedure.procedureSHOULD contain performer
: performer.exists()
should-targetSiteCodewarningSection.entry:entryProcedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:entryProcedure.procedureSHOULD contain text/reference/@value
: text.reference.value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section C1..1SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
shall-procedure-act-procedure: SHALL contain at least one Procedure Activity Procedure
... @nullFlavor 0..1csIf a required section contains no information, the @nullFlavor MAY be set to NI
Binding: CDANullFlavor (required)
... realmCode 0..*CS
... typeId 0..1II
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @assigningAuthorityName 0..1st
.... @displayable 0..1bl
.... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
.... @extension 1..1st
.... templateId:section 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... @ID 0..1xs:ID
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... @moodCode 0..1csBinding: ActMood (required)
Fixed Value: EVN
... id 0..1II
... code 1..1CEHistory of Procedures
Binding: DocumentSectionType (example)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ST
... text 1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: AllLanguages (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 0..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
...... @nullFlavor 0..1csBinding: CDANullFlavor (required)
...... @assigningAuthorityName 0..1st
...... @displayable 0..1bl
...... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
...... @extension 1..1st
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure C1..1ProcedureActivityProcedureBase for all types and resources
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidFixed Value: 2.16.840.1.113883.1.3
..... @extension 1..1st
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredCDANullFlavor
Section.typeId.nullFlavorrequiredCDANullFlavor
Section.templateId:section.nullFlavorrequiredCDANullFlavor
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.codeexampleDocumentSectionType
Section.code.nullFlavorrequiredCDANullFlavor
Section.languageCoderequiredAllLanguages
Section.entry:entryProcedure.nullFlavorrequiredCDANullFlavor
Section.entry:entryProcedure.typeId.nullFlavorrequiredCDANullFlavor
Section.entry:entryProcedure.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredCDANullFlavor
Section.component.typeId.nullFlavorrequiredCDANullFlavor

Constraints

IdGradePath(s)DetailsRequirements
active-high-ts-after-documenterrorSection.entry:entryProcedure.procedureIf the procedure is active and contains a high effectiveTime, this time SHALL be after the ClinicalDocument/effectiveTime
: (statusCode.code = 'active' and effectiveTime.high.value.exists()) implies effectiveTime.high.value > %resource.effectiveTime.value
shall-procedure-act-procedureerrorSectionSHALL contain at least one Procedure Activity Procedure
: nullFlavor.exists() or entry.where(procedure.hasTemplateIdOf('http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure'))
should-authorwarningSection.entry:entryProcedure.procedureSHOULD contain author
: author.exists()
should-performerwarningSection.entry:entryProcedure.procedureSHOULD contain performer
: performer.exists()
should-targetSiteCodewarningSection.entry:entryProcedure.procedureSHOULD contain targetSiteCode
: targetSiteCode.exists()
should-text-ref-valuewarningSection.entry:entryProcedure.procedureSHOULD contain text/reference/@value
: text.reference.value.exists()

This structure is derived from Section

Summary

Mandatory: 9 elements (1 nested mandatory element)

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel