Consolidated CDA Release 2.1 StructureDefinition Publication
2.1 - CI Build United States of America flag

Consolidated CDA Release 2.1 StructureDefinition Publication, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.1). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.1-sd/ and changes regularly. See the Directory of published versions

Logical Model: Procedure Activity Procedure

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureActivityProcedure Version: 2.1
Draft as of 2023-09-29 Computable Name: ProcedureActivityProcedure
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2022-06-01

The common notion of “procedure” is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy). This template represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement, and a creation of a gastrostomy. This template can be used with a contained Product Instance template to represent a device in or on a patient. In this case, targetSiteCode is used to record the location of the device in or on the patient’s body. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity template. Procedure Activity Procedure Usage Note: Common practice in the industry has shown that Procedure Activity 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 Procedure Activity 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 CDAR2.Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure CDAR2.ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
... classCode 1..1cs
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.14
..... extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-19207: 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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
4515-32984: If the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
.... originalText 0..1ED
..... reference 0..1TEL
...... value C0..1url4515-19206: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
... statusCode 1..1CS
.... code 1..1csBinding: ProcedureAct statusCode (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... methodCode C0..1CE4515-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... specimen C0..*Specimen4515-16842: This specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
.... specimenRole 1..1SpecimenRole
..... id C0..*II4515-29744: If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
... Slices for performer 0..*Performer2Slice: Unordered, Open by value:assignedEntity
.... performer:performer1 0..*Performer2performer
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... addr 1..*AD
...... telecom 1..*TEL
...... assignedPerson 0..1Person
....... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... representedOrganization 0..1Organization
....... id 0..*II
....... name 0..*ON
....... telecom 1..*TEL
....... addr 1..*AD
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... typeCode 1..1csFixed Value: DEV
..... participantRole 1..1ProductInstanceBase for all types and resources
.... participant:participant2 0..*Participant2participant
..... typeCode 1..1csFixed Value: LOC
..... participantRole 1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:act, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... inversionInd 1..1blFixed Value: true
..... encounter 1..1Encounter
...... classCode 1..1cs
...... moodCode 1..1csFixed Value: EVN
...... id C1..1II4515-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
.... entryRelationship:entryRelationship2 0..1EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... substanceAdministration 1..1MedicationActivityBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship7 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.statusCode.coderequiredProcedureAct statusCode
Procedure.priorityCoderequiredActPriority
Procedure.targetSiteCoderequiredBody Site Value Set

Constraints

IdGradePath(s)DetailsRequirements
4515-7890errorProcedure.methodCodeMethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
:
4515-16842errorProcedure.specimenThis specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
:
4515-16843warningProcedure.entryRelationship:entryRelationship1.encounter.idSet the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
:
4515-19206errorProcedure.code.originalText.reference.valueThis reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
:
4515-19207warningProcedure.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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
:
4515-29744warningProcedure.specimen.specimenRole.idIf you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
:
4515-32984warningProcedure.codeIf the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
:
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1CDAR2.ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @classCode 1..1csBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.14
..... @extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-19207: 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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
4515-32984: If the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
.... originalText 0..1ED
..... reference 0..1TEL
...... @value C0..1url4515-19206: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csBinding: ProcedureAct statusCode (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... methodCode C0..1CE4515-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... specimen C0..*Specimen4515-16842: This specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
.... specimenRole 1..1SpecimenRole
..... id C0..*II4515-29744: If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
... Slices for performer 0..*Performer2Slice: Unordered, Open by value:assignedEntity
.... performer:performer1 0..*Performer2performer
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... addr 1..*AD
...... telecom 1..*TEL
...... assignedPerson 0..1Person
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... representedOrganization 0..1Organization
....... id 0..*II
....... name 0..*ON
....... telecom 1..*TEL
....... addr 1..*AD
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: DEV
..... participantRole 1..1ProductInstanceBase for all types and resources
.... participant:participant2 0..*Participant2participant
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LOC
..... participantRole 1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:act, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... encounter 1..1Encounter
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: ENC
...... @moodCode 1..1csFixed Value: EVN
...... id C1..1II4515-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
.... entryRelationship:entryRelationship2 0..1EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... substanceAdministration C1..1MedicationActivityBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship7 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.statusCode.coderequiredProcedureAct statusCode
Procedure.priorityCoderequiredActPriority
Procedure.targetSiteCoderequiredBody Site Value Set
Procedure.participant:participant1.typeCoderequiredFixed Value: DEV
Procedure.participant:participant2.typeCoderequiredFixed Value: LOC
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship1.encounter.classCoderequiredFixed Value: ENC
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship7.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
1098-30800warningProcedure.entryRelationship:entryRelationship4.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
4515-7890errorProcedure.methodCodeMethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
:
4515-16842errorProcedure.specimenThis specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
:
4515-16843warningProcedure.entryRelationship:entryRelationship1.encounter.idSet the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
:
4515-19206errorProcedure.code.originalText.reference.valueThis reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
:
4515-19207warningProcedure.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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
:
4515-29744warningProcedure.specimen.specimenRole.idIf you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
:
4515-32984warningProcedure.codeIf the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
:
81-9371errorProcedure.performer:performer1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorProcedure.performer:performer1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
pn-no-lserrorProcedure.performer:performer1.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1CDAR2.ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
Base for all types and resources
... @classCode 1..1csBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1csFixed Value: EVN
... realmCode 0..*CS
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.14
..... @extension 1..1stRequired Pattern: 2022-06-01
... id 1..*II
... code C1..1CD4515-19207: 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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
4515-32984: If the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 0..1cs
.... @codeSystem 0..1oid, uuid, ruid
.... @codeSystemName 0..1st
.... @codeSystemVersion 0..1st
.... @displayName 0..1st
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @charset 0..1cs
..... @compression 0..1csBinding: CompressionAlgorithm (required)
..... @integrityCheck 0..1bin
..... @integrityCheckAlgorithm 0..1csBinding: IntegrityCheckAlgorithm (required)
..... @language 0..1cs
..... @mediaType 0..1cs
..... @representation 0..1cs
..... data[x] 0..1
...... dataStringstring(st)
...... dataBase64Binarybase64Binary(bin)
..... reference 0..1TEL
...... @nullFlavor 0..1csBinding: NullFlavor (required)
...... @value C0..1url4515-19206: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
...... useablePeriod 0..*
....... useablePeriodIVL_TS
....... useablePeriodEIVL_TS
....... useablePeriodPIVL_TS
....... useablePeriodSXPR_TS
...... @use 0..*csBinding: AddressUse (required)
..... thumbnail 0..1ED
.... qualifier 0..*CR
.... translation 0..*CD
... @negationInd 0..1bl
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csBinding: ProcedureAct statusCode (required)
.... @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_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode C0..1CE4515-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
... approachSiteCode 0..*CD
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... subject 0..1Subject
... specimen C0..*Specimen4515-16842: This specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
..... @classCode 0..1csBinding: RoleClassSpecimen (required)
Fixed Value: SPEC
..... templateId 0..*II
..... id C0..*II4515-29744: If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
..... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
..... specimenPlayingEntity 0..1PlayingEntity
... Slices for performer 0..*Performer2Slice: Unordered, Open by value:assignedEntity
.... performer:performer1 0..*Performer2performer
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @typeCode 0..1csBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... modeCode 0..1CE
..... assignedEntity 1..1AssignedEntity
...... @classCode 0..1csBinding: RoleClassAssignedEntity (required)
Fixed Value: ASSIGNED
...... templateId 0..*II
...... id 1..*II
...... sdtcIdentifiedBy 0..*IdentifiedByXML Namespace: urn:hl7-org:sdtc
XML: identifiedBy (urn:hl7-org:sdtc)
...... code 0..1CEBinding: v3 Code System RoleCode (extensible)
...... addr 1..*AD
...... telecom 1..*TEL
...... assignedPerson 0..1Person
....... @classCode 0..1csBinding: EntityClassLivingSubject (required)
Fixed Value: PSN
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... templateId 0..*II
....... name C1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
....... sdtcAsPatientRelationship 0..*CEXML Namespace: urn:hl7-org:sdtc
XML: asPatientRelationship (urn:hl7-org:sdtc)
...... representedOrganization 0..1Organization
....... @nullFlavor 0..1csBinding: NullFlavor (required)
....... @classCode 0..1csBinding: EntityClassOrganization (required)
Fixed Value: ORG
....... @determinerCode 0..1csBinding: EntityDeterminer (required)
Fixed Value: INSTANCE
....... realmCode 0..*CS
....... typeId 0..1II
....... templateId 0..*II
....... id 0..*II
....... name 0..*ON
....... telecom 1..*TEL
....... addr 1..*AD
....... standardIndustryClassCode 0..1CEBinding: OrganizationIndustryClassNAICS (extensible)
....... asOrganizationPartOf 0..1OrganizationPartOf
... author 0..*AuthorParticipationBase for all types and resources
... informant 0..*Informant
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: DEV
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ProductInstanceBase for all types and resources
.... participant:participant2 0..*Participant2participant
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @typeCode 1..1csBinding: ParticipationType (required)
Fixed Value: LOC
..... @contextControlCode 0..1csBinding: ContextControl (required)
Fixed Value: OP
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... sdtcFunctionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: functionCode (urn:hl7-org:sdtc)
..... time 0..1IVL_TS
..... awarenessCode 0..1CE
..... participantRole 1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:act, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... @inversionInd 1..1blFixed Value: true
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 1..1Encounter
...... @classCode 1..1csBinding: ActClass (required)
Fixed Value: ENC
...... @moodCode 1..1csFixed Value: EVN
...... realmCode 0..*CS
...... typeId 0..1II
...... templateId 0..*II
...... id C1..1II4515-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
...... code 0..1CDBinding: ActEncounterCode (extensible)
...... text 0..1ED
...... statusCode 0..1CSBinding: ActStatus (required)
...... effectiveTime 0..1IVL_TS
...... sdtcDischargeDispositionCode 0..1CEXML Namespace: urn:hl7-org:sdtc
XML: dischargeDispositionCode (urn:hl7-org:sdtc)
...... priorityCode 0..1CEBinding: ActPriority (extensible)
...... subject 0..1Subject
...... specimen 0..*Specimen
...... performer 0..*Performer2
...... author 0..*Author
...... informant 0..*Informant
...... participant 0..*Participant2
...... entryRelationship 0..*EntryRelationship
...... reference 0..*Reference
...... precondition 0..*Precondition
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship2 0..1EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... 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 1..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:entryRelationship3 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... 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 1..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:entryRelationship4 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... 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 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration C1..1MedicationActivityBase for all types and resources
..... supply 0..1Supply
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... 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 0..1Act
..... encounter 0..1Encounter
..... observation 1..1ReactionObservationBase 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..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... 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 1..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:entryRelationship7 0..*EntryRelationshipentryRelationship
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... 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 1..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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.templateId:templateId1.nullFlavorrequiredNullFlavor
Procedure.code.nullFlavorrequiredNullFlavor
Procedure.code.originalText.nullFlavorrequiredNullFlavor
Procedure.code.originalText.compressionrequiredCompressionAlgorithm
Procedure.code.originalText.integrityCheckAlgorithmrequiredIntegrityCheckAlgorithm
Procedure.code.originalText.reference.nullFlavorrequiredNullFlavor
Procedure.code.originalText.reference.userequiredAddressUse
Procedure.statusCoderequiredActStatus
Procedure.statusCode.nullFlavorrequiredNullFlavor
Procedure.statusCode.coderequiredProcedureAct statusCode
Procedure.priorityCoderequiredActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.targetSiteCoderequiredBody Site Value Set
Procedure.specimen.nullFlavorrequiredNullFlavor
Procedure.specimen.typeCoderequiredFixed Value: SPC
Procedure.specimen.specimenRole.classCoderequiredFixed Value: SPEC
Procedure.performer:performer1.nullFlavorrequiredNullFlavor
Procedure.performer:performer1.typeCoderequiredFixed Value: PRF
Procedure.performer:performer1.assignedEntity.classCoderequiredFixed Value: ASSIGNED
Procedure.performer:performer1.assignedEntity.codeextensibleRoleCode
Procedure.performer:performer1.assignedEntity.assignedPerson.classCoderequiredFixed Value: PSN
Procedure.performer:performer1.assignedEntity.assignedPerson.determinerCoderequiredFixed Value: INSTANCE
Procedure.performer:performer1.assignedEntity.representedOrganization.nullFlavorrequiredNullFlavor
Procedure.performer:performer1.assignedEntity.representedOrganization.classCoderequiredFixed Value: ORG
Procedure.performer:performer1.assignedEntity.representedOrganization.determinerCoderequiredFixed Value: INSTANCE
Procedure.performer:performer1.assignedEntity.representedOrganization.standardIndustryClassCodeextensibleOrganizationIndustryClassNAICS
Procedure.participant:participant1.nullFlavorrequiredNullFlavor
Procedure.participant:participant1.typeCoderequiredFixed Value: DEV
Procedure.participant:participant1.contextControlCoderequiredFixed Value: OP
Procedure.participant:participant2.nullFlavorrequiredNullFlavor
Procedure.participant:participant2.typeCoderequiredFixed Value: LOC
Procedure.participant:participant2.contextControlCoderequiredFixed Value: OP
Procedure.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship1.encounter.classCoderequiredFixed Value: ENC
Procedure.entryRelationship:entryRelationship1.encounter.codeextensibleActEncounterCode
Procedure.entryRelationship:entryRelationship1.encounter.statusCoderequiredActStatus
Procedure.entryRelationship:entryRelationship1.encounter.priorityCodeextensibleActPriority
Procedure.entryRelationship:entryRelationship2.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship3.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship4.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship6.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship7.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship7.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
1098-30800warningProcedure.entryRelationship:entryRelationship4.substanceAdministrationMedication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800).
:
4515-7890errorProcedure.methodCodeMethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
:
4515-16842errorProcedure.specimenThis specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
:
4515-16843warningProcedure.entryRelationship:entryRelationship1.encounter.idSet the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
:
4515-19206errorProcedure.code.originalText.reference.valueThis reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
:
4515-19207warningProcedure.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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
:
4515-29744warningProcedure.specimen.specimenRole.idIf you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
:
4515-32984warningProcedure.codeIf the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
:
81-9371errorProcedure.performer:performer1.assignedEntity.assignedPerson.nameThe content of name **SHALL** be either a conformant Patient Name (PTN.US.FIELDED), or a string (CONF:81-9371).
:
81-9372errorProcedure.performer:performer1.assignedEntity.assignedPerson.nameThe string **SHALL NOT** contain name parts (CONF:81-9372).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
pn-no-lserrorProcedure.performer:performer1.assignedEntity.assignedPerson.nameNo PN name part may have a qualifier of LS.
: (delimiter | family | given | prefix | suffix).where(qualifier = 'LS').empty()

This structure is derived from CDAR2.Procedure

Differential View

This structure is derived from CDAR2.Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure CDAR2.ProcedureXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @classCode, @moodCode, realmCode, typeId, templateId, id, code, @negationInd, text, statusCode, effectiveTime, priorityCode, languageCode, methodCode, approachSiteCode, targetSiteCode, subject, specimen, performer, author, informant, participant, entryRelationship, reference, precondition
... classCode 1..1cs
... moodCode 1..1csFixed Value: EVN
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.14
..... extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-19207: 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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
4515-32984: If the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
.... originalText 0..1ED
..... reference 0..1TEL
...... value C0..1url4515-19206: This reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
... statusCode 1..1CS
.... code 1..1csBinding: ProcedureAct statusCode (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (required)
... methodCode C0..1CE4515-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... specimen C0..*Specimen4515-16842: This specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
.... specimenRole 1..1SpecimenRole
..... id C0..*II4515-29744: If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
... Slices for performer 0..*Performer2Slice: Unordered, Open by value:assignedEntity
.... performer:performer1 0..*Performer2performer
..... assignedEntity 1..1AssignedEntity
...... id 1..*II
...... addr 1..*AD
...... telecom 1..*TEL
...... assignedPerson 0..1Person
....... name 1..*USRealmPersonNamePNUSFIELDEDBase for all types and resources
...... representedOrganization 0..1Organization
....... id 0..*II
....... name 0..*ON
....... telecom 1..*TEL
....... addr 1..*AD
... author 0..*AuthorParticipationBase for all types and resources
... Slices for participant 0..*Participant2Slice: Unordered, Open by value:participantRole, value:typeCode
.... participant:participant1 0..*Participant2participant
..... typeCode 1..1csFixed Value: DEV
..... participantRole 1..1ProductInstanceBase for all types and resources
.... participant:participant2 0..*Participant2participant
..... typeCode 1..1csFixed Value: LOC
..... participantRole 1..1ServiceDeliveryLocationBase for all types and resources
... Slices for entryRelationship 0..*EntryRelationshipSlice: Unordered, Open by value:act, value:typeCode
.... entryRelationship:entryRelationship1 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... inversionInd 1..1blFixed Value: true
..... encounter 1..1Encounter
...... classCode 1..1cs
...... moodCode 1..1csFixed Value: EVN
...... id C1..1II4515-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
.... entryRelationship:entryRelationship2 0..1EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... substanceAdministration 1..1MedicationActivityBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... observation 1..1ReactionObservationBase for all types and resources
.... entryRelationship:entryRelationship6 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship7 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... act 1..1EntryReferenceBase for all types and resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.statusCode.coderequiredProcedureAct statusCode
Procedure.priorityCoderequiredActPriority
Procedure.targetSiteCoderequiredBody Site Value Set

Constraints

IdGradePath(s)DetailsRequirements
4515-7890errorProcedure.methodCodeMethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:4515-7890).
:
4515-16842errorProcedure.specimenThis specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
:
4515-16843warningProcedure.entryRelationship:entryRelationship1.encounter.idSet the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
:
4515-19206errorProcedure.code.originalText.reference.valueThis reference/@value **SHALL** begin with a '#' and **SHALL** point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
:
4515-19207warningProcedure.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: 2.16.840.1.113762.1.4.1247.9) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
:
4515-29744warningProcedure.specimen.specimenRole.idIf you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id **SHOULD** be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
:
4515-32984warningProcedure.codeIf the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Procedures](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.789/expansion) **DYNAMIC** (CONF:4515-32984).
: