Consolidated CDA Release 2.2
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Consolidated CDA Release 2.2, published by Health Level Seven. This is not an authorized publication; it is the continuous build for version 2.2). This version is based on the current content of https://github.com/HL7/CDA-ccda-2.2/ and changes regularly. See the Directory of published versions

Resource Profile: Procedures Section (entries required)

Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.7.1 Version: 2.2
Active as of 2022-05-13 Computable Name: ProceduresSectionentriesrequired
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.2.7.1:2014-06-09

This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of “procedure” is broader than that specified by the HL7 Version 3 Reference Information Model (RIM), therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures that alter the physical condition of a patient (e.g., splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (e.g., EEG). Act is for all other types of procedures (e.g., dressing change).

Usage:

Formal Views of Profile Content

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

This structure is derived from ProceduresSectionEntriesOptional

Summary

Mandatory: 9 elements

Slices

This structure defines the following Slices:

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

This structure is derived from ProceduresSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptional
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... entry 1..*Element

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptional
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I1..*ElementSlice: Unordered, Open by profile:observation
.... entry:entryProcedure I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedure
.... entry:entryAct I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1ProcedureActivityAct
.... entry:entryObservation I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1ProcedureActivityObservation
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

This structure is derived from ProceduresSectionEntriesOptional

Summary

Mandatory: 9 elements

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from ProceduresSectionEntriesOptional

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptional
... nullFlavor 0..1codeRequired Pattern: NI
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... entry 1..*Element

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1ProceduresSectionEntriesOptional
... ID 0..1string
... nullFlavor 0..1codeBinding: NullFlavor (required)
Required Pattern: NI
... classCode 1..1code​Binding: http://terminology.hl7.org/ValueSet/v3-ActClassOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7
..... extension 1..1stringRequired Pattern: 2014-06-09
.... templateId:secondary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: 47519-4
.... codeSystem 1..1stringRequired Pattern: 2.16.840.1.113883.6.1
.... codeSystemName 0..1string
.... codeSystemVersion 0..1string
.... displayName 0..1string
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
.... originalText 0..1ED
.... translation 0..*CD
... title 1..1ED
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... Slices for entry I1..*ElementSlice: Unordered, Open by profile:observation
.... entry:entryProcedure I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... procedure 1..1ProcedureActivityProcedure
.... entry:entryAct I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... act 1..1ProcedureActivityAct
.... entry:entryObservation I0..*Element
..... typeCode 1..1code
..... contextConductionInd 1..1boolean
..... observation 1..1ProcedureActivityObservation
... component 0..*Element
.... typeCode 1..1codeFixed Value: COMP
.... contextConductionInd 1..1boolean
.... section 1..1Section

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredPattern: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:primary.nullFlavorrequiredNullFlavor
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage
Section.subject.typeCoderequiredFixed Value: SBJ
Section.subject.contextControlCoderequiredFixed Value: OP
Section.subject.awarenessCodeextensibleTargetAwareness
Section.informant.typeCoderequiredFixed Value: INF
Section.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
only-one-statementerrorSection.entrySHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:entryProcedureSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:entryActSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
only-one-statementerrorSection.entry:entryObservationSHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act.
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1