Consolidated CDA Release 2.2
2.2 - CI Build
Consolidated CDA Release 2.2
2.2 - CI Build
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
| Official URL: http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.4.14 | Version: 2.2 | |||
| Active as of 2022-05-13 | Computable Name: ProcedureActivityProcedure | |||
| Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.14:2014-06-09 | ||||
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 (V2) template.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Procedure
This structure is derived from CDAR2.Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 1..1 | CDAR2.Procedure | ||
  classCode | 1..1 | code | ||
| moodCode | 1..1 | code | Required Pattern: EVN | |
  Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
   templateId:primary | 1..1 | II | ||
  root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.14 | |
  extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | I | 1..1 | CD | 1098-19207: 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), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19207). |
 originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
 value | I | 0..1 | uri | 1098-19206: 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:1098-19206). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProcedureAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| methodCode | I | 0..1 | CE | 1098-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:1098-7890). |
| targetSiteCode | 0..* | CD | In the case of an implanted medical device, targetSiteCode is used to record the location of the device, in or on the patient's body. Binding: Body Site Value Set (required) | |
| code | 1..1 | string | Binding: Body Site Value Set (required) | |
| specimen | I | 0..* | Specimen | 1098-16842: This specimen is for representing specimens obtained from a procedure (CONF:1098-16842). |
| specimenRole | 1..1 | SpecimenRole | ||
| id | I | 0..* | II | 1098-29744: 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:1098-29744). |
| Slices for performer | 0..* | Performer2 | Slice: Unordered, Open by value:assignedEntity | |
| performer:performer1 | 0..* | Performer2 | ||
 assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| representedOrganization | 0..1 | Organization | ||
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| author | 0..* | AuthorParticipation | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, profile:participantRole | |
 participant:product | 0..* | Participant2 | ||
 typeCode | 1..1 | code | Required Pattern: DEV | |
| participantRole | 1..1 | ProductInstance | ||
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Required Pattern: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | ||
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation, profile:act, profile:substanceAdministration | |
| entryRelationship:encounter | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| encounter | 1..1 | Encounter | ||
| classCode | 1..1 | code | Required Pattern: ENC | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| id | I | 1..1 | II | 1098-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:1098-16843). |
| entryRelationship:instruction | 0..1 | Element | ||
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| act | 1..1 | Instruction | ||
| entryRelationship:indication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: RSON | |
| observation | 1..1 | Indication | ||
| entryRelationship:medication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| substanceAdministration | 1..1 | MedicationActivity | ||
| entryRelationship:reaction | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | ReactionObservation | ||
| Documentation for this format | ||||
This structure is derived from CDAR2.Procedure
Differential View
This structure is derived from CDAR2.Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 1..1 | CDAR2.Procedure | ||
| classCode | 1..1 | code | ||
| moodCode | 1..1 | code | Required Pattern: EVN | |
| Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
| templateId:primary | 1..1 | II | ||
| root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.14 | |
| extension | 1..1 | string | Required Pattern: 2014-06-09 | |
| id | 1..* | II | ||
| code | I | 1..1 | CD | 1098-19207: 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), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19207). |
| originalText | 0..1 | ED | ||
| reference | 0..1 | TEL | ||
| value | I | 0..1 | uri | 1098-19206: 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:1098-19206). |
| statusCode | 1..1 | CS | ||
| code | 1..1 | string | Binding: ProcedureAct statusCode (required) | |
| effectiveTime | 0..1 | IVL_TS | ||
| priorityCode | 0..1 | CE | Binding: ActPriority (required) | |
| methodCode | I | 0..1 | CE | 1098-7890: MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:1098-7890). |
| targetSiteCode | 0..* | CD | In the case of an implanted medical device, targetSiteCode is used to record the location of the device, in or on the patient's body. Binding: Body Site Value Set (required) | |
| code | 1..1 | string | Binding: Body Site Value Set (required) | |
| specimen | I | 0..* | Specimen | 1098-16842: This specimen is for representing specimens obtained from a procedure (CONF:1098-16842). |
| specimenRole | 1..1 | SpecimenRole | ||
| id | I | 0..* | II | 1098-29744: 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:1098-29744). |
| Slices for performer | 0..* | Performer2 | Slice: Unordered, Open by value:assignedEntity | |
| performer:performer1 | 0..* | Performer2 | ||
| assignedEntity | 1..1 | AssignedEntity | ||
| id | 1..* | II | ||
| addr | 1..* | AD | ||
| telecom | 1..* | TEL | ||
| representedOrganization | 0..1 | Organization | ||
| id | 0..* | II | ||
| name | 0..* | ON | ||
| telecom | 1..1 | TEL | ||
| addr | 1..1 | AD | ||
| author | 0..* | AuthorParticipation | ||
| Slices for participant | 0..* | Participant2 | Slice: Unordered, Open by value:typeCode, profile:participantRole | |
| participant:product | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Required Pattern: DEV | |
| participantRole | 1..1 | ProductInstance | ||
| participant:location | 0..* | Participant2 | ||
| typeCode | 1..1 | code | Required Pattern: LOC | |
| participantRole | 1..1 | ServiceDeliveryLocation | ||
| Slices for entryRelationship | 0..* | Element | Slice: Unordered, Open by profile:observation, profile:act, profile:substanceAdministration | |
| entryRelationship:encounter | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| encounter | 1..1 | Encounter | ||
| classCode | 1..1 | code | Required Pattern: ENC | |
| moodCode | 1..1 | code | Required Pattern: EVN | |
| id | I | 1..1 | II | 1098-16843: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:1098-16843). |
| entryRelationship:instruction | 0..1 | Element | ||
| typeCode | 1..1 | code | Required Pattern: SUBJ | |
| inversionInd | 1..1 | boolean | Required Pattern: true | |
| act | 1..1 | Instruction | ||
| entryRelationship:indication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: RSON | |
| observation | 1..1 | Indication | ||
| entryRelationship:medication | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| substanceAdministration | 1..1 | MedicationActivity | ||
| entryRelationship:reaction | 0..* | Element | ||
| typeCode | 1..1 | code | Required Pattern: COMP | |
| observation | 1..1 | ReactionObservation | ||
| Documentation for this format | ||||
Snapshot View
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet / Code |
| Procedure.classCode | required | Fixed Value: PROC |
| Procedure.templateId:primary.nullFlavor | required | NullFlavor |
| Procedure.code.nullFlavor | required | NullFlavor |
| Procedure.code.originalText.nullFlavor | required | NullFlavor |
| Procedure.code.originalText.compression | required | CompressionAlgorithm |
| Procedure.code.originalText.integrityCheckAlgorithm | required | IntegrityCheckAlgorithm |
| Procedure.code.originalText.reference.nullFlavor | required | NullFlavor |
| Procedure.code.originalText.reference.use | required | AddressUse |
| Procedure.statusCode | required | ActStatus |
| Procedure.statusCode.nullFlavor | required | NullFlavor |
| Procedure.statusCode.code | required | ProcedureAct statusCode |
| Procedure.priorityCode | required | ActPriority |
| Procedure.languageCode | required | HumanLanguage |
| Procedure.targetSiteCode | required | BodySiteValueSet |
| Procedure.targetSiteCode.nullFlavor | required | NullFlavor |
| Procedure.targetSiteCode.code | required | BodySiteValueSet |
| Procedure.subject.typeCode | required | Fixed Value: SBJ |
| Procedure.subject.contextControlCode | required | Fixed Value: OP |
| Procedure.subject.awarenessCode | extensible | TargetAwareness |
| Procedure.specimen.nullFlavor | required | NullFlavor |
| Procedure.specimen.typeCode | required | Fixed Value: SPC |
| Procedure.specimen.specimenRole.classCode | required | Fixed Value: SPEC |
| Procedure.performer:performer1.nullFlavor | required | NullFlavor |
| Procedure.performer:performer1.typeCode | required | Fixed Value: PRF |
| Procedure.performer:performer1.assignedEntity.classCode | required | Fixed Value: ASSIGNED |
| Procedure.performer:performer1.assignedEntity.code | extensible | RoleCode |
| Procedure.performer:performer1.assignedEntity.representedOrganization.classCode | required | Fixed Value: ORG |
| Procedure.performer:performer1.assignedEntity.representedOrganization.determinerCode | required | Fixed Value: INSTANCE |
| Procedure.performer:performer1.assignedEntity.representedOrganization.standardIndustryClassCode | extensible | OrganizationIndustryClassNAICS |
| Procedure.informant.typeCode | required | Fixed Value: INF |
| Procedure.informant.contextControlCode | required | Fixed Value: OP |
| Procedure.participant:product.nullFlavor | required | NullFlavor |
| Procedure.participant:product.typeCode | required | Pattern: DEV |
| Procedure.participant:product.contextControlCode | required | Fixed Value: OP |
| Procedure.participant:location.nullFlavor | required | NullFlavor |
| Procedure.participant:location.typeCode | required | Pattern: LOC |
| Procedure.participant:location.contextControlCode | required | Fixed Value: OP |
| Id | Grade | Path | Details | Requirements |
| 1098-19207 | warning | Procedure.code | 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), and **MAY** be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19207). : | |
| 1098-19206 | error | Procedure.code.originalText.reference.value | 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:1098-19206). : | |
| 1098-7890 | error | Procedure.methodCode | MethodCode **SHALL NOT** conflict with the method inherent in Procedure / code (CONF:1098-7890). : | |
| 1098-16842 | error | Procedure.specimen | This specimen is for representing specimens obtained from a procedure (CONF:1098-16842). : | |
| 1098-29744 | warning | Procedure.specimen.specimenRole.id | 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:1098-29744). : | |
| proc-er-1 | error | Procedure.entryRelationship | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| proc-er-1 | error | Procedure.entryRelationship:encounter | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| proc-er-1 | error | Procedure.entryRelationship:instruction | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| proc-er-1 | error | Procedure.entryRelationship:indication | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| proc-er-1 | error | Procedure.entryRelationship:medication | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 | |
| 1098-30800 | warning | Procedure.entryRelationship:medication.substanceAdministration | Medication Activity **SHOULD** include doseQuantity **OR** rateQuantity (CONF:1098-30800). : | |
| proc-er-1 | error | Procedure.entryRelationship:reaction | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |
IG © 2019+ Health Level Seven. Package hl7.cda.us.ccdar2dot2#2.2 based on FHIR 4.0.1. Generated 2022-05-13
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