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: Planned Procedure

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PlannedProcedure Version: 3.0.0-ballot
Draft as of 2023-12-21 Computable Name: PlannedProcedure
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2022-06-01

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.

Planned Procedure Usage Note: Common practice in the industry has shown that Planned Procedure is the usually implemented CDA template for any type of intervention or procedure regardless of if the “immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient”, or not. As a result, it is recommended to use Planned Procedure when sending procedures also thought of as “interventions” such as “Home Environment Evaluation” or “Assessment of nutritional status”.

Usage:

Formal Views of Profile Content

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

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C1..1ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:planned-proc 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... @classCode 1..1cs
... @moodCode 1..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... code C1..1CDIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet Social Determinant of Health Service Request (CONF:4515-32993)
Binding: Social Determinants of Health Service Requests (preferred)
4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CS
.... @code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:entryRelationship1 0..*EntryRelationshipThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... @typeCode 1..1csFixed Value: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipThe following entryRelationship represents the indication for the procedure.
..... @typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipThe following entryRelationship captures any instructions associated with the planned procedure.
..... @typeCode 1..1csFixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
..... @typeCode 1..1csFixed Value: COMP
..... act 1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csFixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csFixed Value: RSON
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.moodCoderequiredPlannedMoodCodeActEncounterProcedure
Procedure.codepreferredSocialDeterminantsOfHealthServiceRequests
Procedure.targetSiteCoderequiredBodySiteValueSet

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
: codeSystem = '2.16.840.1.113883.6.1' or codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.285' or codeSystem = '2.16.840.1.113883.6.13'
should-authorwarningProcedureSHOULD contain author
: author.exists()
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C1..1ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:planned-proc 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... @classCode 1..1csBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... code C1..1CDIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet Social Determinant of Health Service Request (CONF:4515-32993)
Binding: Social Determinants of Health Service Requests (preferred)
4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:entryRelationship1 0..*EntryRelationshipThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipThe following entryRelationship represents the indication for the procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipThe following entryRelationship captures any instructions associated with the planned procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act C1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act C1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... act C1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.moodCoderequiredPlannedMoodCodeActEncounterProcedure
Procedure.codepreferredSocialDeterminantsOfHealthServiceRequests
Procedure.statusCoderequiredActStatus
Procedure.targetSiteCoderequiredBodySiteValueSet
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
: codeSystem = '2.16.840.1.113883.6.1' or codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.285' or codeSystem = '2.16.840.1.113883.6.13'
should-authorwarningProcedureSHOULD contain author
: author.exists()
should-authorwarningProcedure.entryRelationship:entryRelationship1.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-effectiveTimewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observation, Procedure.entryRelationship:entryRelationship3.act, Procedure.entryRelationship:entryRelationship4.act, Procedure.entryRelationship:entryRelationship5.observation, Procedure.entryRelationship:entryRelationship6.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C1..1ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
... @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
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:planned-proc 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... @classCode 1..1csBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... id 1..*II
... code C1..1CDIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet Social Determinant of Health Service Request (CONF:4515-32993)
Binding: Social Determinants of Health Service Requests (preferred)
4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
... @negationInd 0..1bl
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csFixed Value: active
.... @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)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... priorityCode 0..1CEBinding: ActPriority (example)
... languageCode 0..1CSBinding: AllLanguages (required)
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:entryRelationship1 0..*EntryRelationshipThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1PriorityPreferenceBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship2 0..*EntryRelationshipThe following entryRelationship represents the indication for the procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1IndicationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship3 0..*EntryRelationshipThe following entryRelationship captures any instructions associated with the planned procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1InstructionBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship4 0..*EntryRelationshipThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1PlannedCoverageBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship5 0..*EntryRelationshipWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1AssessmentScaleObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship6 0..*EntryRelationshipWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1EntryReferenceBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.nullFlavorrequiredCDANullFlavor
Procedure.typeId.nullFlavorrequiredCDANullFlavor
Procedure.templateId:planned-proc.nullFlavorrequiredCDANullFlavor
Procedure.classCoderequiredFixed Value: PROC
Procedure.moodCoderequiredPlannedMoodCodeActEncounterProcedure
Procedure.codepreferredSocialDeterminantsOfHealthServiceRequests
Procedure.text.nullFlavorrequiredCDANullFlavor
Procedure.text.compressionrequiredCDACompressionAlgorithm
Procedure.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Procedure.text.mediaTypeexampleMediaType
Procedure.text.representationrequiredBinaryDataEncoding
Procedure.statusCoderequiredActStatus
Procedure.statusCode.nullFlavorrequiredCDANullFlavor
Procedure.priorityCodeexampleActPriority
Procedure.languageCoderequiredAllLanguages
Procedure.targetSiteCoderequiredBodySiteValueSet
Procedure.entryRelationship:entryRelationship1.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship1.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship2.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship3.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship4.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship5.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship6.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
: codeSystem = '2.16.840.1.113883.6.1' or codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.285' or codeSystem = '2.16.840.1.113883.6.13'
should-authorwarningProcedureSHOULD contain author
: author.exists()
should-authorwarningProcedure.entryRelationship:entryRelationship1.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-effectiveTimewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observation, Procedure.entryRelationship:entryRelationship3.act, Procedure.entryRelationship:entryRelationship4.act, Procedure.entryRelationship:entryRelationship5.observation, Procedure.entryRelationship:entryRelationship6.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Procedure

Summary

Mandatory: 8 elements (7 nested mandatory elements)
Fixed Value: 8 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Procedure.templateId is sliced based on the values of value:root, value:extension
  • The element Procedure.entryRelationship is sliced based on the values of profile:act, profile:observation

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C1..1ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:planned-proc 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... @classCode 1..1cs
... @moodCode 1..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... code C1..1CDIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet Social Determinant of Health Service Request (CONF:4515-32993)
Binding: Social Determinants of Health Service Requests (preferred)
4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CS
.... @code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:entryRelationship1 0..*EntryRelationshipThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... @typeCode 1..1csFixed Value: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipThe following entryRelationship represents the indication for the procedure.
..... @typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipThe following entryRelationship captures any instructions associated with the planned procedure.
..... @typeCode 1..1csFixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
..... @typeCode 1..1csFixed Value: COMP
..... act 1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csFixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csFixed Value: RSON
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.moodCoderequiredPlannedMoodCodeActEncounterProcedure
Procedure.codepreferredSocialDeterminantsOfHealthServiceRequests
Procedure.targetSiteCoderequiredBodySiteValueSet

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
: codeSystem = '2.16.840.1.113883.6.1' or codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.285' or codeSystem = '2.16.840.1.113883.6.13'
should-authorwarningProcedureSHOULD contain author
: author.exists()
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C1..1ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:planned-proc 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... @classCode 1..1csBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... code C1..1CDIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet Social Determinant of Health Service Request (CONF:4515-32993)
Binding: Social Determinants of Health Service Requests (preferred)
4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:entryRelationship1 0..*EntryRelationshipThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... observation C1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipThe following entryRelationship represents the indication for the procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipThe following entryRelationship captures any instructions associated with the planned procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act C1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act C1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation C1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... act C1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.moodCoderequiredPlannedMoodCodeActEncounterProcedure
Procedure.codepreferredSocialDeterminantsOfHealthServiceRequests
Procedure.statusCoderequiredActStatus
Procedure.targetSiteCoderequiredBodySiteValueSet
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
: codeSystem = '2.16.840.1.113883.6.1' or codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.285' or codeSystem = '2.16.840.1.113883.6.13'
should-authorwarningProcedureSHOULD contain author
: author.exists()
should-authorwarningProcedure.entryRelationship:entryRelationship1.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-effectiveTimewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observation, Procedure.entryRelationship:entryRelationship3.act, Procedure.entryRelationship:entryRelationship4.act, Procedure.entryRelationship:entryRelationship5.observation, Procedure.entryRelationship:entryRelationship6.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C1..1ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @nullFlavor, realmCode, typeId, templateId, @classCode, @moodCode, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition, sdtcPrecondition2, sdtcInFulfillmentOf1
Base for all types and resources
Instances of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
should-text-ref-value: SHOULD contain text/reference/@value
should-effectiveTime: SHOULD contain effectiveTime
should-author: SHOULD contain author
... @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
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:planned-proc 1..1II
..... @nullFlavor 0..1csBinding: CDANullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... @classCode 1..1csBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... id 1..*II
... code C1..1CDIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet Social Determinant of Health Service Request (CONF:4515-32993)
Binding: Social Determinants of Health Service Requests (preferred)
4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
... @negationInd 0..1bl
... text 0..1EDSHOULD reference the portion of section narrative text corresponding to this entry
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @compression 0..1csBinding: CompressionAlgorithm (required)
.... @integrityCheck 0..1bin
.... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (2.0.0) (required)
.... @language 0..1cs
.... @mediaType 0..1csBinding: MediaType (example)
.... @representation 0..1csBinding: Binary Data Encoding Value Set (required)
.... xmlText 0..1stAllows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
.... reference C0..1TELvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
.... thumbnail 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: CDANullFlavor (required)
.... @code 1..1csFixed Value: active
.... @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)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... priorityCode 0..1CEBinding: ActPriority (example)
... languageCode 0..1CSBinding: AllLanguages (required)
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... informant 0..*Informant
... participant 0..*Participant2
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by profile:act, profile:observation
.... entryRelationship:entryRelationship1 0..*EntryRelationshipThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1PriorityPreferenceBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship2 0..*EntryRelationshipThe following entryRelationship represents the indication for the procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1IndicationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship3 0..*EntryRelationshipThe following entryRelationship captures any instructions associated with the planned procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1InstructionBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship4 0..*EntryRelationshipThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1PlannedCoverageBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship5 0..*EntryRelationshipWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation C1..1AssessmentScaleObservationBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship6 0..*EntryRelationshipWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
..... @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 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act C1..1EntryReferenceBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... reference 0..*Reference
... precondition 0..*Precondition
... sdtcPrecondition2 0..*Precondition2XML Namespace: urn:hl7-org:sdtc
XML: precondition2 (urn:hl7-org:sdtc)
... sdtcInFulfillmentOf1 0..*InFulfillmentOf1XML Namespace: urn:hl7-org:sdtc
XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.nullFlavorrequiredCDANullFlavor
Procedure.typeId.nullFlavorrequiredCDANullFlavor
Procedure.templateId:planned-proc.nullFlavorrequiredCDANullFlavor
Procedure.classCoderequiredFixed Value: PROC
Procedure.moodCoderequiredPlannedMoodCodeActEncounterProcedure
Procedure.codepreferredSocialDeterminantsOfHealthServiceRequests
Procedure.text.nullFlavorrequiredCDANullFlavor
Procedure.text.compressionrequiredCDACompressionAlgorithm
Procedure.text.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Procedure.text.mediaTypeexampleMediaType
Procedure.text.representationrequiredBinaryDataEncoding
Procedure.statusCoderequiredActStatus
Procedure.statusCode.nullFlavorrequiredCDANullFlavor
Procedure.priorityCodeexampleActPriority
Procedure.languageCoderequiredAllLanguages
Procedure.targetSiteCoderequiredBodySiteValueSet
Procedure.entryRelationship:entryRelationship1.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship1.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship2.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship3.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship4.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship5.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship6.typeId.nullFlavorrequiredCDANullFlavor
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
: codeSystem = '2.16.840.1.113883.6.1' or codeSystem = '2.16.840.1.113883.6.96' or codeSystem = '2.16.840.1.113883.6.12' or codeSystem = '2.16.840.1.113883.6.4' or codeSystem = '2.16.840.1.113883.6.285' or codeSystem = '2.16.840.1.113883.6.13'
should-authorwarningProcedureSHOULD contain author
: author.exists()
should-authorwarningProcedure.entryRelationship:entryRelationship1.observationSHOULD contain author
: author.exists()
should-effectiveTimewarningProcedureSHOULD contain effectiveTime
: effectiveTime.exists()
should-effectiveTimewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observationSHOULD contain effectiveTime
: effectiveTime.exists()
should-text-ref-valuewarningProcedureSHOULD contain text/reference/@value
: text.reference.value.exists()
should-text-ref-valuewarningProcedure.entryRelationship:entryRelationship1.observation, Procedure.entryRelationship:entryRelationship2.observation, Procedure.entryRelationship:entryRelationship3.act, Procedure.entryRelationship:entryRelationship4.act, Procedure.entryRelationship:entryRelationship5.observation, Procedure.entryRelationship:entryRelationship6.actSHOULD contain text/reference/@value
: text.reference.value.exists()
value-starts-octothorpeerrorProcedure.text.referenceIf reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
: value.exists() implies value.startsWith('#')

This structure is derived from Procedure

Summary

Mandatory: 8 elements (7 nested mandatory elements)
Fixed Value: 8 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Procedure.templateId is sliced based on the values of value:root, value:extension
  • The element Procedure.entryRelationship is sliced based on the values of profile:act, profile:observation

 

Other representations of profile: CSV, Excel