Consolidated CDA Release 2.1 StructureDefinition Publication
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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: Procedures Section

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProceduresSection Version: 2.1
Draft as of 2023-09-29 Computable Name: ProceduresSection
Other Identifiers: id: 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 Activity Procedure is for procedures that alter the physical condition of a patient (e.g., splenectomy).

Usage:

Formal Views of Profile Content

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

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
... nullFlavor 0..1csFixed Value: NI
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1csRequired Pattern: 47519-4
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 1..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: NI
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text S1..1xhtml
... Slices for entry 1..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredFixed Value: NI
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @ID 0..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: NI
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @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
.... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 1..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredFixed Value: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry:entryProcedure.nullFlavorrequiredNullFlavor
Section.entry:entryProcedure.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Section

Summary

Mandatory: 9 elements (1 nested mandatory element)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Differential View

This structure is derived from CDAR2.Section

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
... nullFlavor 0..1csFixed Value: NI
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CE
.... code 1..1csRequired Pattern: 47519-4
.... codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text 1..1xhtml
... Slices for entry 1..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: NI
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
... text S1..1xhtml
... Slices for entry 1..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredFixed Value: NI
Section.codeextensibleDocumentSectionType

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Section 1..1CDAR2.SectionXML Namespace: urn:hl7-org:v3
Elements defined in Ancestors: @ID, @nullFlavor, @classCode, @moodCode, templateId, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component
Base for all types and resources
... @ID 0..1xs:ID
... @nullFlavor 0..1csBinding: NullFlavor (required)
Fixed Value: NI
... @classCode 0..1csBinding: ActClassRecordOrganizer (required)
Fixed Value: DOCSECT
... Slices for templateId 2..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:secondary 1..1II
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... @assigningAuthorityName 0..1st
..... @displayable 0..1bl
..... @root 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.10.20.22.2.7.1
..... @extension 1..1stRequired Pattern: 2014-06-09
... id 0..1II
... code 1..1CEBinding: DocumentSectionType (extensible)
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... @code 1..1csRequired Pattern: 47519-4
.... @codeSystem 1..1oid, uuid, ruidRequired Pattern: 2.16.840.1.113883.6.1
.... @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
.... translation 0..*CD
... title 1..1ST
... text S1..1xhtml
... confidentialityCode 0..1CE
... languageCode 0..1CSBinding: HumanLanguage (required)
... subject 0..1Subject
... author 0..*Author
... informant 0..*Informant
... Slices for entry 1..*EntryIf section/@nullFlavor is not present there SHALL be at least one entry conformant to Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14:2014-06-09)
Slice: Unordered, Open by profile:observation
.... entry:entryProcedure 0..*Entry
..... @nullFlavor 0..1csBinding: NullFlavor (required)
..... realmCode 0..*CS
..... typeId 0..1II
..... templateId 0..*II
..... @typeCode 0..1csBinding: x_ActRelationshipEntry (required)
..... @contextConductionInd 0..1blFixed Value: true
..... act 0..1Act
..... encounter 0..1Encounter
..... observation 0..1Observation
..... observationMedia 0..1ObservationMedia
..... organizer 0..1Organizer
..... procedure 1..1ProcedureActivityProcedureBase for all types and resources
..... regionOfInterest 0..1RegionOfInterest
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
... component 0..*InfrastructureRoot
.... @nullFlavor 0..1csBinding: NullFlavor (required)
.... realmCode 0..*CS
.... typeId 0..1II
.... templateId 0..*II
.... @typeCode 0..1csFixed Value: COMP
.... @contextConductionInd 0..1blFixed Value: true
.... section 1..1Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Section.nullFlavorrequiredFixed Value: NI
Section.classCoderequiredFixed Value: DOCSECT
Section.moodCoderequiredFixed Value: EVN
Section.templateId:secondary.nullFlavorrequiredNullFlavor
Section.codeextensibleDocumentSectionType
Section.code.nullFlavorrequiredNullFlavor
Section.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Section.entry:entryProcedure.nullFlavorrequiredNullFlavor
Section.entry:entryProcedure.typeCoderequiredXActRelationshipEntry
Section.component.nullFlavorrequiredNullFlavor

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())

This structure is derived from CDAR2.Section

Summary

Mandatory: 9 elements (1 nested mandatory element)
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel