This page is part of the CCDA: Consolidated CDA Release (v4.0.0-ballot: CCDA 4.0 Ballot 1) generated with FHIR (HL7® FHIR® Standard) v5.0.0. The current version which supersedes this version is 3.0.0. For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureDescriptionSection | Version: 4.0.0-ballot | |||
Draft as of 2024-12-20 | Computable Name: ProcedureDescriptionSection | |||
Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.27 |
The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints![]() |
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Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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0..0 | |||
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1..1 | CE | Procedure Narrative | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
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Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
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1..1 | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
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0..1 | II | ||
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1..1 | CE | Procedure Narrative | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..1 | CE | ||
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0..1 | CS | Binding: AllLanguages (required) | |
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0..1 | Subject | ||
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0..* | Author | ||
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0..* | Informant | ||
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0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |
Name | Flags | Card. | Type | Description & Constraints![]() |
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1..1 | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
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0..1 | II | ||
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1..1 | CE | Procedure Narrative | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..1 | CE | ||
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0..1 | CS | Binding: AllLanguages (required) | |
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0..1 | Subject | ||
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0..* | Author | ||
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0..* | Informant | ||
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0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |
Differential View
This structure is derived from Section
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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1..* | II | Slice: Unordered, Open by value:root | |
![]() ![]() ![]() ![]() |
1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
![]() ![]() ![]() ![]() ![]() |
0..0 | |||
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1..1 | CE | Procedure Narrative | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
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Key Elements View
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
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1..1 | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
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0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
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0..1 | II | ||
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1..1 | CE | Procedure Narrative | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
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0..1 | CE | ||
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0..1 | CS | Binding: AllLanguages (required) | |
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0..1 | Subject | ||
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0..* | Author | ||
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0..* | Informant | ||
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0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
1..1 | Section | XML 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 Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
![]() ![]() ![]() ![]() |
0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() |
0..1 | st | ||
![]() ![]() ![]() ![]() |
0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
![]() ![]() ![]() ![]() |
1..1 | st | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() ![]() |
0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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0..1 | xs:ID | ||
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0..1 | cs | Binding: ActClassRecordOrganizer (required) Fixed Value: DOCSECT | |
![]() ![]() ![]() |
0..1 | cs | Binding: CDAActMood (required) Fixed Value: EVN | |
![]() ![]() ![]() |
0..1 | II | ||
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1..1 | CE | Procedure Narrative | |
![]() ![]() ![]() ![]() |
0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() |
1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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0..1 | st | ||
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0..1 | st | ||
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0..1 | st | ||
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0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |
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0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |
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0..1 | ED | ||
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0..* | CD | ||
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1..1 | ST | ||
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1..1 | xhtml | ||
![]() ![]() ![]() |
0..1 | CE | ||
![]() ![]() ![]() |
0..1 | CS | Binding: AllLanguages (required) | |
![]() ![]() ![]() |
0..1 | Subject | ||
![]() ![]() ![]() |
0..* | Author | ||
![]() ![]() ![]() |
0..* | Informant | ||
![]() ![]() ![]() |
0..* | Entry | ||
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0..* | InfrastructureRoot | ||
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0..1 | cs | Binding: CDANullFlavor (required) | |
![]() ![]() ![]() ![]() |
0..* | CS | ||
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C | 0..1 | II | II-1: An II instance must have either a root or an nullFlavor. |
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0..1 | cs | Binding: CDANullFlavor (required) | |
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0..1 | st | ||
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0..1 | bl | ||
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1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |
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1..1 | st | ||
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0..* | II | ||
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0..1 | cs | Fixed Value: COMP | |
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0..1 | bl | Fixed Value: true | |
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1..1 | Section | ||
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Path | Conformance | ValueSet / Code | URI |
Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages from the FHIR Standard | |
Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Id | Grade | Path(s) | Details | Requirements |
II-1 | error | Section.typeId, Section.component.typeId | An II instance must have either a root or an nullFlavor. : root.exists() or nullFlavor.exists() |