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/2.16.840.1.113883.10.20.22.4.41 | Version: 2.2 | |||
Active as of 2022-05-13 | Computable Name: PlannedProcedure | |||
Other Identifiers: : urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2014-06-09 |
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.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CDAR2.Procedure
Summary
Mandatory: 9 elements (9 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from CDAR2.Procedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 1..1 | CDAR2.Procedure | ||
classCode | 1..1 | code | Required Pattern: PROC | |
moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
extension | 1..1 | string | Required Pattern: 2014-06-09 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **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) (CONF:1098-31977). |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: active | |
effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
Slices for entryRelationship | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act | |
entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |
typeCode | 1..1 | code | Required Pattern: REFR | |
observation | 1..1 | PriorityPreference | ||
entryRelationship:indication | 0..* | Element | The following entryRelationship represents the indication for the procedure. | |
typeCode | 1..1 | code | Required Pattern: RSON | |
observation | 1..1 | Indication | ||
entryRelationship:instruction | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. | |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
inversionInd | 1..1 | boolean | Required Pattern: true | |
act | 1..1 | Instruction | ||
entryRelationship:plannedCoverage | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: COMP | |
act | 1..1 | PlannedCoverage | ||
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 1..1 | CDAR2.Procedure | ||
classCode | 1..1 | code | Binding: ActClassProcedure (required) Fixed Value: PROC | |
moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
extension | 1..1 | string | Required Pattern: 2014-06-09 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **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) (CONF:1098-31977). |
negationInd | 0..1 | boolean | ||
text | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: active | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
approachSiteCode | 0..* | CD | ||
targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
subject | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
relatedSubject | 1..1 | RelatedSubject | ||
specimen | 0..* | Specimen | ||
performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
informant | 0..* | Element | ||
typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 0..1 | RelatedEntity | ||
participant | 0..* | Participant2 | ||
Slices for entryRelationship | I | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act |
entryRelationship:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | ||
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
(Choice of one) | 1..1 | |||
observation | 0..1 | Observation | ||
regionOfInterest | 0..1 | RegionOfInterest | ||
observationMedia | 0..1 | ObservationMedia | ||
substanceAdministration | 0..1 | SubstanceAdministration | ||
supply | 0..1 | Supply | ||
procedure | 0..1 | Procedure | ||
encounter | 0..1 | Encounter | ||
organizer | 0..1 | Organizer | ||
act | 0..1 | Act | ||
entryRelationship:priorityPreference | I | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. |
typeCode | 1..1 | code | Required Pattern: REFR | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
observation | 1..1 | PriorityPreference | ||
entryRelationship:indication | I | 0..* | Element | The following entryRelationship represents the indication for the procedure. |
typeCode | 1..1 | code | Required Pattern: RSON | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
observation | 1..1 | Indication | ||
entryRelationship:instruction | I | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
inversionInd | 1..1 | boolean | Required Pattern: true | |
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
act | 1..1 | Instruction | ||
entryRelationship:plannedCoverage | I | 0..* | Element | |
typeCode | 1..1 | code | Required Pattern: COMP | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
act | 1..1 | PlannedCoverage | ||
reference | 0..* | Element | ||
typeCode | 1..1 | code | ||
seperatableInd | 0..1 | BL | ||
externalAct | 0..1 | ExternalAct | ||
externalObservation | 0..1 | ExternalObservation | ||
externalProcedure | 0..1 | ExternalProcedure | ||
externalDocument | 0..1 | ExternalDocument | ||
precondition | 0..* | Precondition | ||
Documentation for this format |
This structure is derived from CDAR2.Procedure
Summary
Mandatory: 9 elements (9 nested mandatory elements)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CDAR2.Procedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 1..1 | CDAR2.Procedure | ||
classCode | 1..1 | code | Required Pattern: PROC | |
moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
extension | 1..1 | string | Required Pattern: 2014-06-09 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **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) (CONF:1098-31977). |
statusCode | 1..1 | CS | ||
code | 1..1 | string | Required Pattern: active | |
effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
Slices for entryRelationship | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act | |
entryRelationship:priorityPreference | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. | |
typeCode | 1..1 | code | Required Pattern: REFR | |
observation | 1..1 | PriorityPreference | ||
entryRelationship:indication | 0..* | Element | The following entryRelationship represents the indication for the procedure. | |
typeCode | 1..1 | code | Required Pattern: RSON | |
observation | 1..1 | Indication | ||
entryRelationship:instruction | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. | |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
inversionInd | 1..1 | boolean | Required Pattern: true | |
act | 1..1 | Instruction | ||
entryRelationship:plannedCoverage | 0..* | Element | ||
typeCode | 1..1 | code | Required Pattern: COMP | |
act | 1..1 | PlannedCoverage | ||
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 1..1 | CDAR2.Procedure | ||
classCode | 1..1 | code | Binding: ActClassProcedure (required) Fixed Value: PROC | |
moodCode | 1..1 | code | Binding: Planned moodCode (Act/Encounter/Procedure) (required) | |
realmCode | 0..* | CS | ||
typeId | 0..1 | II | ||
Slices for templateId | 0..* | II | Slice: Unordered, Open by value:root, value:extension | |
templateId:primary | 1..1 | II | ||
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
assigningAuthorityName | 0..1 | string | ||
displayable | 0..1 | boolean | ||
root | 1..1 | string | Required Pattern: 2.16.840.1.113883.10.20.22.4.41 | |
extension | 1..1 | string | Required Pattern: 2014-06-09 | |
id | 1..* | II | ||
code | I | 1..1 | CD | 1098-31977: The procedure/code in a planned procedure **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) (CONF:1098-31977). |
negationInd | 0..1 | boolean | ||
text | 0..1 | ED | ||
statusCode | 1..1 | CS | Binding: ActStatus (required) | |
nullFlavor | 0..1 | code | Binding: NullFlavor (required) | |
code | 1..1 | string | Required Pattern: active | |
sdtcValueSet | 0..1 | string | XML: valueSet (urn:hl7-org:sdtc) | |
sdtcValueSetVersion | 0..1 | string | XML: valueSetVersion (urn:hl7-org:sdtc) | |
effectiveTime | 0..1 | IVL_TS | The effectiveTime in a planned procedure represents the time that the procedure should occur. | |
priorityCode | 0..1 | CE | Binding: ActPriority (extensible) | |
languageCode | 0..1 | CS | Binding: HumanLanguage (required) | |
methodCode | 0..* | CE | In a planned procedure the provider may suggest that a procedure should be performed using a particular method.
MethodCode *SHALL NOT* conflict with the method inherent in Procedure / code. | |
approachSiteCode | 0..* | CD | ||
targetSiteCode | 0..* | CD | The targetSiteCode is used to identify the part of the body of concern for the planned procedure. Binding: Body Site Value Set (required) | |
subject | 0..1 | Element | ||
typeCode | 1..1 | code | Binding: ParticipationTargetSubject (required) Fixed Value: SBJ | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
awarenessCode | 0..1 | CE | Binding: TargetAwareness (extensible) | |
relatedSubject | 1..1 | RelatedSubject | ||
specimen | 0..* | Specimen | ||
performer | 0..* | Performer2 | The clinician who is expected to perform the procedure could be identified using procedure/performer. | |
author | 0..1 | AuthorParticipation | The author in a planned procedure represents the clinician who is requesting or planning the procedure. | |
informant | 0..* | Element | ||
typeCode | 1..1 | code | Binding: ParticipationInformationGenerator (required) Fixed Value: INF | |
contextControlCode | 1..1 | code | Binding: ContextControl (required) Fixed Value: OP | |
assignedEntity | 0..1 | AssignedEntity | ||
relatedEntity | 0..1 | RelatedEntity | ||
participant | 0..* | Participant2 | ||
Slices for entryRelationship | I | 0..* | Element | The following entryRelationship represents the insurance coverage the patient may have for the procedure. Slice: Unordered, Open by value:act |
entryRelationship:All Slices | Content/Rules for all slices | |||
typeCode | 1..1 | code | ||
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
(Choice of one) | 1..1 | |||
observation | 0..1 | Observation | ||
regionOfInterest | 0..1 | RegionOfInterest | ||
observationMedia | 0..1 | ObservationMedia | ||
substanceAdministration | 0..1 | SubstanceAdministration | ||
supply | 0..1 | Supply | ||
procedure | 0..1 | Procedure | ||
encounter | 0..1 | Encounter | ||
organizer | 0..1 | Organizer | ||
act | 0..1 | Act | ||
entryRelationship:priorityPreference | I | 0..* | Element | The following entryRelationship represents the priority that a patient or a provider places on the procedure. |
typeCode | 1..1 | code | Required Pattern: REFR | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
observation | 1..1 | PriorityPreference | ||
entryRelationship:indication | I | 0..* | Element | The following entryRelationship represents the indication for the procedure. |
typeCode | 1..1 | code | Required Pattern: RSON | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
observation | 1..1 | Indication | ||
entryRelationship:instruction | I | 0..* | Element | The following entryRelationship captures any instructions associated with the planned procedure. |
typeCode | 1..1 | code | Required Pattern: SUBJ | |
inversionInd | 1..1 | boolean | Required Pattern: true | |
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
act | 1..1 | Instruction | ||
entryRelationship:plannedCoverage | I | 0..* | Element | |
typeCode | 1..1 | code | Required Pattern: COMP | |
inversionInd | 0..1 | boolean | ||
contextConductionInd | 1..1 | boolean | ||
sequenceNumber | 0..1 | INT | ||
negationInd | 0..1 | boolean | ||
seperatableInd | 0..1 | BL | ||
act | 1..1 | PlannedCoverage | ||
reference | 0..* | Element | ||
typeCode | 1..1 | code | ||
seperatableInd | 0..1 | BL | ||
externalAct | 0..1 | ExternalAct | ||
externalObservation | 0..1 | ExternalObservation | ||
externalProcedure | 0..1 | ExternalProcedure | ||
externalDocument | 0..1 | ExternalDocument | ||
precondition | 0..* | Precondition | ||
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
Procedure.classCode | required | Fixed Value: PROC |
Procedure.moodCode | required | Planned moodCode (Act/Encounter/Procedure) |
Procedure.templateId:primary.nullFlavor | required | NullFlavor |
Procedure.statusCode | required | ActStatus |
Procedure.statusCode.nullFlavor | required | NullFlavor |
Procedure.priorityCode | extensible | ActPriority |
Procedure.languageCode | required | HumanLanguage |
Procedure.targetSiteCode | required | BodySiteValueSet |
Procedure.subject.typeCode | required | Fixed Value: SBJ |
Procedure.subject.contextControlCode | required | Fixed Value: OP |
Procedure.subject.awarenessCode | extensible | TargetAwareness |
Procedure.informant.typeCode | required | Fixed Value: INF |
Procedure.informant.contextControlCode | required | Fixed Value: OP |
Id | Grade | Path | Details | Requirements |
1098-31977 | warning | Procedure.code | The procedure/code in a planned procedure **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) (CONF:1098-31977). : | |
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:priorityPreference | 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: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:plannedCoverage | Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act : (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1 |