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: Planned Procedure

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PlannedProcedure Version: 2.1
Draft as of 2023-09-29 Computable Name: PlannedProcedure
Other Identifiers: id: urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2022-06-01

This template represents planned alterations of the patient’s physical condition. Examples of such procedures are tracheostomy, knee replacement, and craniectomy. The priority of the procedure to the patient and provider is communicated through Priority Preference. The effectiveTime indicates the time when the procedure is intended to take place and authorTime indicates when the documentation of the plan occurred. The Planned Procedure Template may also indicate the potential insurance coverage for the procedure.

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

Usage:

Formal Views of Profile Content

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

This structure is derived from 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..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
4515-32993: If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
... statusCode 1..1CS
.... code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TS
... methodCode 0..*CE
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... performer 0..*Performer2
... author 0..1AuthorParticipationBase 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: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... act 1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 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.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.targetSiteCoderequiredBody Site Value Set

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
:
4515-32993warningProcedure.codeIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
:
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..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
4515-32993: If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TS
... methodCode 0..*CE
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... performer 0..*Performer2
... author 0..1AuthorParticipationBase 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: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act 1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 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.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.statusCoderequiredActStatus
Procedure.targetSiteCoderequiredBody Site Value Set
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
:
4515-32993warningProcedure.codeIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
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..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... 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: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... id 1..*II
... code C1..1CD4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
4515-32993: If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
... @negationInd 0..1bl
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: active
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CE
... approachSiteCode 0..*CD
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..1AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... 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: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1PriorityPreferenceBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship2 0..*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: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: 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: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 1..1PlannedCoverageBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship5 0..*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: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 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.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.templateId:templateId1.nullFlavorrequiredNullFlavor
Procedure.statusCoderequiredActStatus
Procedure.statusCode.nullFlavorrequiredNullFlavor
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.targetSiteCoderequiredBody Site Value Set
Procedure.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
:
4515-32993warningProcedure.codeIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

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..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
4515-32993: If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
... statusCode 1..1CS
.... code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TS
... methodCode 0..*CE
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... performer 0..*Performer2
... author 0..1AuthorParticipationBase 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: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: SUBJ
..... inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: COMP
..... act 1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... typeCode 1..1csFixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 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.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.targetSiteCoderequiredBody Site Value Set

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
:
4515-32993warningProcedure.codeIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
:

Key Elements View

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..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... Slices for templateId 1..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:templateId1 1..1IItemplateId
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... code C1..1CD4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
4515-32993: If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
... statusCode 1..1CSBinding: ActStatus (required)
.... @code 1..1csFixed Value: active
... effectiveTime 0..1IVL_TS
... methodCode 0..*CE
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... performer 0..*Performer2
... author 0..1AuthorParticipationBase 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: REFR
..... observation 1..1PriorityPreferenceBase for all types and resources
.... entryRelationship:entryRelationship2 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1IndicationBase for all types and resources
.... entryRelationship:entryRelationship3 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: SUBJ
..... @inversionInd 1..1blFixed Value: true
..... act 1..1InstructionBase for all types and resources
.... entryRelationship:entryRelationship4 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: COMP
..... act 1..1PlannedCoverageBase for all types and resources
.... entryRelationship:entryRelationship5 0..*EntryRelationshipentryRelationship
..... @typeCode 1..1csBinding: x_ActRelationshipEntryRelationship (required)
Fixed Value: RSON
..... observation 1..1AssessmentScaleObservationBase for all types and resources
.... entryRelationship:entryRelationship6 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.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.statusCoderequiredActStatus
Procedure.targetSiteCoderequiredBody Site Value Set
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
:
4515-32993warningProcedure.codeIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

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..1csBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... 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: 2.16.840.1.113883.10.20.22.4.41
..... @extension 1..1stRequired Pattern: 2022-06-01
... id 1..*II
... code C1..1CD4515-31977: This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
4515-32993: If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
... @negationInd 0..1bl
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csFixed Value: active
.... @sdtcValueSet 0..1oidXML Namespace: urn:hl7-org:sdtc
XML: valueSet (urn:hl7-org:sdtc)
.... @sdtcValueSetVersion 0..1stXML Namespace: urn:hl7-org:sdtc
XML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CE
... approachSiteCode 0..*CD
... targetSiteCode 0..*CDBinding: Body Site Value Set (required)
... subject 0..1Subject
... specimen 0..*Specimen
... performer 0..*Performer2
... author 0..1AuthorParticipationBase for all types and resources
... informant 0..*Informant
... participant 0..*Participant2
... 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: REFR
..... @inversionInd 0..1bl
..... @contextConductionInd 0..1bl
..... @negationInd 0..1bl
..... sequenceNumber 0..1INT
..... seperatableInd 0..1BL
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 1..1PriorityPreferenceBase for all types and resources
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship2 0..*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: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: 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: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 1..1PlannedCoverageBase for all types and resources
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 0..1Procedure
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
.... entryRelationship:entryRelationship5 0..*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: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 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.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.templateId:templateId1.nullFlavorrequiredNullFlavor
Procedure.statusCoderequiredActStatus
Procedure.statusCode.nullFlavorrequiredNullFlavor
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.targetSiteCoderequiredBody Site Value Set
Procedure.entryRelationship:entryRelationship1.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship1.typeCoderequiredFixed Value: REFR
Procedure.entryRelationship:entryRelationship2.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship2.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship3.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship3.typeCoderequiredFixed Value: SUBJ
Procedure.entryRelationship:entryRelationship4.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship4.typeCoderequiredFixed Value: COMP
Procedure.entryRelationship:entryRelationship5.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship5.typeCoderequiredFixed Value: RSON
Procedure.entryRelationship:entryRelationship6.nullFlavorrequiredNullFlavor
Procedure.entryRelationship:entryRelationship6.typeCoderequiredFixed Value: RSON

Constraints

IdGradePath(s)DetailsRequirements
4515-31977warningProcedure.codeThis @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) or CPT (CodeSystem: 2.16.840.1.113883.6.12) or ICD-10-PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113883.6.285) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-31977).
:
4515-32993warningProcedure.codeIf the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion/) **DYNAMIC** (CONF:4515-32993).
:
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Procedure

 

Other representations of profile: CSV, Excel