Consolidated CDA (C-CDA)
3.0.0 - STU3
Consolidated CDA (C-CDA)
3.0.0 - STU3
This page is part of the CCDA: Consolidated CDA Release (v3.0.0: CCDA 3.0) generated with FHIR (HL7® FHIR® Standard) v5.0.0. This is the current published version. For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PlannedProcedure | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: PlannedProcedure | |||
| Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#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:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Procedure |
C | 1..1 | Procedure | XML 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 Instance 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..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
   templateId:planned-proc |
1..1 | II | ||||||||
  @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |||||||
  @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
 @classCode |
1..1 | cs | ||||||||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (Act/Encounter/Procedure)  (required) | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | (USCDI) SDOH Interventions Binding: US Core Procedure Codes (preferred)
| |||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
 reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | ||||||||
| @code |
1..1 | cs | Fixed Value: active | |||||||
| effectiveTime |
0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |||||||
| methodCode |
0..* | CE | In 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..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |||||||
| performer |
0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |||||||
 author |
0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |||||||
 Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
 entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |||||||
 @typeCode |
1..1 | cs | Fixed Value: REFR | |||||||
| observation |
1..1 | PriorityPreference | Base for all types and resources | |||||||
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: RSON | |||||||
| observation |
1..1 | Indication | Base for all types and resources | |||||||
| entryRelationship:instruction |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| act |
1..1 | Instruction | Base for all types and resources | |||||||
| entryRelationship:coverage |
0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: COMP | |||||||
| act |
1..1 | PlannedCoverage | Base for all types and resources | |||||||
| entryRelationship:assessmentScale |
0..* | EntryRelationship | When 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..1 | cs | Fixed Value: RSON | |||||||
| observation |
1..1 | AssessmentScaleObservation | Base for all types and resources | |||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When 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..1 | cs | Fixed Value: RSON | |||||||
| act |
1..1 | EntryReference | Base for all types and resources | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | URI |
| Procedure.moodCode | required | PlannedMoodCodeActEncounterProcedure http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23 | |
| Procedure.code | preferred | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.targetSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Procedure | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 1..1 | Procedure | XML 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 Instance 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..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:planned-proc |
1..1 | II | ||||||||
 @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: ActClassProcedure (required) Fixed Value: PROC | |||||||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | (USCDI) SDOH Interventions Binding: US Core Procedure Codes (preferred)
| |||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @code |
1..1 | cs | Fixed Value: active | |||||||
| effectiveTime |
0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |||||||
| methodCode |
0..* | CE | In 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..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |||||||
| performer |
0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |||||||
| author |
0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| observation |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. | ||||||
| entryRelationship:instruction |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:coverage |
0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| act |
C | 1..1 | PlannedCoverage | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:assessmentScale |
0..* | EntryRelationship | When 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..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When 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..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.classCode | required | Fixed Value: PROChttp://terminology.hl7.org/ValueSet/v3-ActClassProcedure | |
| Procedure.moodCode | required | PlannedMoodCodeActEncounterProcedure http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23 | |
| Procedure.code | preferred | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Procedure.targetSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| Procedure.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:coverage.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:assessmentScale.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:entryReference.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| indication-value | error | Procedure.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| should-author | warning | Procedure | SHOULD contain author : author.exists() | |
| should-author | warning | Procedure.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation, Procedure.entryRelationship:instruction.act, Procedure.entryRelationship:coverage.act, Procedure.entryRelationship:assessmentScale.observation, Procedure.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 1..1 | Procedure | XML 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 Instance 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..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:planned-proc |
1..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: ActClassProcedure (required) Fixed Value: PROC | |||||||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | (USCDI) SDOH Interventions Binding: US Core Procedure Codes (preferred)
| |||||||
| @negationInd |
0..1 | bl | ||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
| @integrityCheck |
0..1 | bin | ||||||||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language |
0..1 | cs | ||||||||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |||||||
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Fixed Value: active | |||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime |
0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||
| methodCode |
0..* | CE | In 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..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |||||||
| subject |
0..1 | Subject | ||||||||
| specimen |
0..* | Specimen | ||||||||
| performer |
0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |||||||
| author |
0..1 | AuthorParticipation | The 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..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
 typeId |
0..1 | II | ||||||||
 @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:instruction |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:coverage |
0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | PlannedCoverage | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:assessmentScale |
0..* | EntryRelationship | When 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..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When 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..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| reference |
0..* | Reference | ||||||||
| precondition |
0..* | Precondition | ||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.templateId:planned-proc.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.classCode | required | Fixed Value: PROChttp://terminology.hl7.org/ValueSet/v3-ActClassProcedure | |
| Procedure.moodCode | required | PlannedMoodCodeActEncounterProcedure http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23 | |
| Procedure.code | preferred | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Procedure.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Procedure.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Procedure.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Procedure.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Procedure.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Procedure.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Procedure.targetSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| Procedure.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:coverage.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:coverage.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:coverage.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:assessmentScale.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:assessmentScale.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:assessmentScale.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:entryReference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:entryReference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:entryReference.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| indication-value | error | Procedure.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| should-author | warning | Procedure | SHOULD contain author : author.exists() | |
| should-author | warning | Procedure.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation, Procedure.entryRelationship:instruction.act, Procedure.entryRelationship:coverage.act, Procedure.entryRelationship:assessmentScale.observation, Procedure.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.text.reference | If 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: 8 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 1..1 | Procedure | XML 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 Instance 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..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:planned-proc |
1..1 | II | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | ||||||||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | (USCDI) SDOH Interventions Binding: US Core Procedure Codes (preferred)
| |||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | ||||||||
| @code |
1..1 | cs | Fixed Value: active | |||||||
| effectiveTime |
0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |||||||
| methodCode |
0..* | CE | In 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..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |||||||
| performer |
0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |||||||
| author |
0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: REFR | |||||||
| observation |
1..1 | PriorityPreference | Base for all types and resources | |||||||
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: RSON | |||||||
| observation |
1..1 | Indication | Base for all types and resources | |||||||
| entryRelationship:instruction |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| act |
1..1 | Instruction | Base for all types and resources | |||||||
| entryRelationship:coverage |
0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the procedure. | |||||||
| @typeCode |
1..1 | cs | Fixed Value: COMP | |||||||
| act |
1..1 | PlannedCoverage | Base for all types and resources | |||||||
| entryRelationship:assessmentScale |
0..* | EntryRelationship | When 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..1 | cs | Fixed Value: RSON | |||||||
| observation |
1..1 | AssessmentScaleObservation | Base for all types and resources | |||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When 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..1 | cs | Fixed Value: RSON | |||||||
| act |
1..1 | EntryReference | Base for all types and resources | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | URI |
| Procedure.moodCode | required | PlannedMoodCodeActEncounterProcedure http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23 | |
| Procedure.code | preferred | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.targetSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 |
| Id | Grade | Path(s) | Details | Requirements |
| should-author | warning | Procedure | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 1..1 | Procedure | XML 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 Instance 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..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:planned-proc |
1..1 | II | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: ActClassProcedure (required) Fixed Value: PROC | |||||||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | (USCDI) SDOH Interventions Binding: US Core Procedure Codes (preferred)
| |||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @code |
1..1 | cs | Fixed Value: active | |||||||
| effectiveTime |
0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |||||||
| methodCode |
0..* | CE | In 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..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |||||||
| performer |
0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |||||||
| author |
0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |||||||
| Slices for entryRelationship |
0..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| observation |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. | ||||||
| entryRelationship:instruction |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:coverage |
0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the procedure. | |||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| act |
C | 1..1 | PlannedCoverage | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:assessmentScale |
0..* | EntryRelationship | When 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..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When 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..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.classCode | required | Fixed Value: PROChttp://terminology.hl7.org/ValueSet/v3-ActClassProcedure | |
| Procedure.moodCode | required | PlannedMoodCodeActEncounterProcedure http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23 | |
| Procedure.code | preferred | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Procedure.targetSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| Procedure.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:coverage.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:assessmentScale.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:entryReference.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| indication-value | error | Procedure.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| should-author | warning | Procedure | SHOULD contain author : author.exists() | |
| should-author | warning | Procedure.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation, Procedure.entryRelationship:instruction.act, Procedure.entryRelationship:coverage.act, Procedure.entryRelationship:assessmentScale.observation, Procedure.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.text.reference | If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative : value.exists() implies value.startsWith('#') |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 1..1 | Procedure | XML 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 Instance 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..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| Slices for templateId |
1..* | II | Slice: Unordered, Open by value:root, value:extension | |||||||
| templateId:planned-proc |
1..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |||||||
| @extension |
1..1 | st | Required Pattern: 2022-06-01 | |||||||
| @classCode |
1..1 | cs | Binding: ActClassProcedure (required) Fixed Value: PROC | |||||||
| @moodCode |
1..1 | cs | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |||||||
| id |
1..* | II | ||||||||
| code |
1..1 | CD | (USCDI) SDOH Interventions Binding: US Core Procedure Codes (preferred)
| |||||||
| @negationInd |
0..1 | bl | ||||||||
| text |
0..1 | ED | SHOULD reference the portion of section narrative text corresponding to this entry | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @compression |
0..1 | cs | Binding: CDACompressionAlgorithm (required) | |||||||
| @integrityCheck |
0..1 | bin | ||||||||
| @integrityCheckAlgorithm |
0..1 | cs | Binding: IntegrityCheckAlgorithm (2.0.0) (required) | |||||||
| @language |
0..1 | cs | ||||||||
| @mediaType |
0..1 | cs | Binding: MediaType (example) | |||||||
| @representation |
0..1 | cs | Binding: CDABinaryDataEncoding (required) | |||||||
| xmlText |
0..1 | st | Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string. | |||||||
| reference |
C | 0..1 | TEL | value-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative | ||||||
| thumbnail |
0..1 | ED | ||||||||
| statusCode |
1..1 | CS | Binding: ActStatus (required) | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @code |
1..1 | cs | Fixed Value: active | |||||||
| @sdtcValueSet |
0..1 | oid | XML Namespace: urn:hl7-org:sdtc XML: valueSet (urn:hl7-org:sdtc) | |||||||
| @sdtcValueSetVersion |
0..1 | st | XML Namespace: urn:hl7-org:sdtc XML: valueSetVersion (urn:hl7-org:sdtc) | |||||||
| effectiveTime |
0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |||||||
| priorityCode |
0..1 | CE | Binding: ActPriority (example) | |||||||
| languageCode |
0..1 | CS | Binding: AllLanguages (required) | |||||||
| methodCode |
0..* | CE | In 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..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |||||||
| subject |
0..1 | Subject | ||||||||
| specimen |
0..* | Specimen | ||||||||
| performer |
0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |||||||
| author |
0..1 | AuthorParticipation | The 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..* | EntryRelationship | Slice: Unordered, Open by profile:act, profile:observation | |||||||
| entryRelationship:priorityPreference |
0..* | EntryRelationship | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: REFR | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | PriorityPreference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime should-author: SHOULD contain author | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:indication |
0..* | EntryRelationship | The following entryRelationship represents the indication for the procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | Indication | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value should-effectiveTime: SHOULD contain effectiveTime indication-value: If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:instruction |
0..* | EntryRelationship | The following entryRelationship captures any instructions associated with the planned procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: SUBJ | |||||||
| @inversionInd |
1..1 | bl | Fixed Value: true | |||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | Instruction | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:coverage |
0..* | EntryRelationship | The following entryRelationship represents the insurance coverage the patient may have for the procedure. | |||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: COMP | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | PlannedCoverage | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:assessmentScale |
0..* | EntryRelationship | When 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..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
0..1 | Act | ||||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
C | 1..1 | AssessmentScaleObservation | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| entryRelationship:entryReference |
0..* | EntryRelationship | When 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..1 | cs | Binding: CDANullFlavor (required) | |||||||
| realmCode |
0..* | CS | ||||||||
| typeId |
0..1 | II | ||||||||
| @nullFlavor |
0..1 | cs | Binding: CDANullFlavor (required) | |||||||
| @assigningAuthorityName |
0..1 | st | ||||||||
| @displayable |
0..1 | bl | ||||||||
| @root |
1..1 | oid, uuid, ruid | Fixed Value: 2.16.840.1.113883.1.3 | |||||||
| @extension |
1..1 | st | ||||||||
| templateId |
0..* | II | ||||||||
| @typeCode |
1..1 | cs | Binding: x_ActRelationshipEntryRelationship (required) Fixed Value: RSON | |||||||
| @inversionInd |
0..1 | bl | ||||||||
| @contextConductionInd |
0..1 | bl | ||||||||
| @negationInd |
0..1 | bl | ||||||||
| sequenceNumber |
0..1 | INT | ||||||||
| seperatableInd |
0..1 | BL | ||||||||
| act |
C | 1..1 | EntryReference | Base for all types and resources should-text-ref-value: SHOULD contain text/reference/@value | ||||||
| encounter |
0..1 | Encounter | ||||||||
| observation |
0..1 | Observation | ||||||||
| observationMedia |
0..1 | ObservationMedia | ||||||||
| organizer |
0..1 | Organizer | ||||||||
| procedure |
0..1 | Procedure | ||||||||
| regionOfInterest |
0..1 | RegionOfInterest | ||||||||
| substanceAdministration |
0..1 | SubstanceAdministration | ||||||||
| supply |
0..1 | Supply | ||||||||
| reference |
0..* | Reference | ||||||||
| precondition |
0..* | Precondition | ||||||||
| sdtcPrecondition2 |
0..* | Precondition2 | XML Namespace: urn:hl7-org:sdtc XML: precondition2 (urn:hl7-org:sdtc) | |||||||
| sdtcInFulfillmentOf1 |
0..* | InFulfillmentOf1 | XML Namespace: urn:hl7-org:sdtc XML: inFulfillmentOf1 (urn:hl7-org:sdtc) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.templateId:planned-proc.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.classCode | required | Fixed Value: PROChttp://terminology.hl7.org/ValueSet/v3-ActClassProcedure | |
| Procedure.moodCode | required | PlannedMoodCodeActEncounterProcedure http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23 | |
| Procedure.code | preferred | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.text.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.text.compression | required | CDACompressionAlgorithmhttp://hl7.org/cda/stds/core/ValueSet/CDACompressionAlgorithm | |
| Procedure.text.integrityCheckAlgorithm | required | IntegrityCheckAlgorithmhttp://terminology.hl7.org/ValueSet/v3-IntegrityCheckAlgorithm|2.0.0 | |
| Procedure.text.mediaType | example | MediaTypehttp://terminology.hl7.org/ValueSet/v3-MediaType | |
| Procedure.text.representation | required | BinaryDataEncodinghttp://hl7.org/cda/stds/core/ValueSet/BinaryDataEncoding | |
| Procedure.statusCode | required | ActStatushttp://terminology.hl7.org/ValueSet/v3-ActStatus | |
| Procedure.statusCode.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.priorityCode | example | ActPriorityhttp://terminology.hl7.org/ValueSet/v3-ActPriority | |
| Procedure.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Procedure.targetSiteCode | required | BodySiteValueSet http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9 | |
| Procedure.entryRelationship:priorityPreference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:priorityPreference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:priorityPreference.typeCode | required | Fixed Value: REFRhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:indication.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:indication.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:indication.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:instruction.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:instruction.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:instruction.typeCode | required | Fixed Value: SUBJhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:coverage.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:coverage.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:coverage.typeCode | required | Fixed Value: COMPhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:assessmentScale.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:assessmentScale.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:assessmentScale.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship | |
| Procedure.entryRelationship:entryReference.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:entryReference.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Procedure.entryRelationship:entryReference.typeCode | required | Fixed Value: RSONhttp://terminology.hl7.org/ValueSet/v3-xActRelationshipEntryRelationship |
| Id | Grade | Path(s) | Details | Requirements |
| indication-value | error | Procedure.entryRelationship:indication.observation | If the ID element does not reference a problem recorded elsewhere in the document, then observation/value must be populated with a coded entry. : value.exists() or (%resource.descendants().ofType(CDA.Observation).where(id.exists($this.root = %context.id.first().root and $this.extension ~ %context.id.first().extension) and value.exists())) | |
| should-author | warning | Procedure | SHOULD contain author : author.exists() | |
| should-author | warning | Procedure.entryRelationship:priorityPreference.observation | SHOULD contain author : author.exists() | |
| should-effectiveTime | warning | Procedure | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-effectiveTime | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation | SHOULD contain effectiveTime : effectiveTime.exists() | |
| should-text-ref-value | warning | Procedure | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| should-text-ref-value | warning | Procedure.entryRelationship:priorityPreference.observation, Procedure.entryRelationship:indication.observation, Procedure.entryRelationship:instruction.act, Procedure.entryRelationship:coverage.act, Procedure.entryRelationship:assessmentScale.observation, Procedure.entryRelationship:entryReference.act | SHOULD contain text/reference/@value : text.reference.value.exists() | |
| value-starts-octothorpe | error | Procedure.text.reference | If 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: 8 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccda#3.0.0 based on FHIR 5.0.0. Generated 2024-05-18
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