Consolidated CDA Release 2.2
2.2 - CI Build United States of America flag

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

Resource Profile: Planned Procedure

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:

Formal Views of Profile Content

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:

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

This structure is derived from CDAR2.Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1CDAR2.Procedure
... classCode 1..1codeRequired Pattern: PROC
... moodCode 1..1codeBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... extension 1..1stringRequired Pattern: 2014-06-09
... code I1..1CD1098-31977: 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..1CS
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... Slices for entryRelationship 0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
Slice: Unordered, Open by value:act
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreference
.... entryRelationship:indication 0..*ElementThe following entryRelationship represents the indication for the procedure.
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:instruction 0..*ElementThe following entryRelationship captures any instructions associated with the planned procedure.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... act 1..1Instruction
.... entryRelationship:plannedCoverage 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1PlannedCoverage

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1CDAR2.Procedure
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1codeBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code I1..1CD1098-31977: 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..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: active
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementThe 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..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:priorityPreference I0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreference
.... entryRelationship:indication I0..*ElementThe following entryRelationship represents the indication for the procedure.
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:instruction I0..*ElementThe following entryRelationship captures any instructions associated with the planned procedure.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:plannedCoverage I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PlannedCoverage
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco 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:

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

Differential View

This structure is derived from CDAR2.Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1CDAR2.Procedure
... classCode 1..1codeRequired Pattern: PROC
... moodCode 1..1codeBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... extension 1..1stringRequired Pattern: 2014-06-09
... code I1..1CD1098-31977: 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..1CS
.... code 1..1stringRequired Pattern: active
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... Slices for entryRelationship 0..*ElementThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
Slice: Unordered, Open by value:act
.... entryRelationship:priorityPreference 0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... typeCode 1..1codeRequired Pattern: REFR
..... observation 1..1PriorityPreference
.... entryRelationship:indication 0..*ElementThe following entryRelationship represents the indication for the procedure.
..... typeCode 1..1codeRequired Pattern: RSON
..... observation 1..1Indication
.... entryRelationship:instruction 0..*ElementThe following entryRelationship captures any instructions associated with the planned procedure.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... act 1..1Instruction
.... entryRelationship:plannedCoverage 0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... act 1..1PlannedCoverage

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1CDAR2.Procedure
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1codeBinding: Planned moodCode (Act/Encounter/Procedure) (required)
... realmCode 0..*CS
... Slices for templateId 0..*IISlice: Unordered, Open by value:root, value:extension
.... templateId:primary 1..1II
..... nullFlavor 0..1codeBinding: NullFlavor (required)
..... assigningAuthorityName 0..1string
..... displayable 0..1boolean
..... root 1..1stringRequired Pattern: 2.16.840.1.113883.10.20.22.4.41
..... extension 1..1stringRequired Pattern: 2014-06-09
... id 1..*II
... code I1..1CD1098-31977: 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..1boolean
... text 0..1ED
... statusCode 1..1CSBinding: ActStatus (required)
.... nullFlavor 0..1codeBinding: NullFlavor (required)
.... code 1..1stringRequired Pattern: active
.... sdtcValueSet 0..1stringXML: valueSet (urn:hl7-org:sdtc)
.... sdtcValueSetVersion 0..1stringXML: valueSetVersion (urn:hl7-org:sdtc)
... effectiveTime 0..1IVL_TSThe effectiveTime in a planned procedure represents the time that the procedure should occur.
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CEIn 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..*CDThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
Binding: Body Site Value Set (required)
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Specimen
... performer 0..*Performer2The clinician who is expected to perform the procedure could be identified using procedure/performer.
... author 0..1AuthorParticipationThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... Slices for entryRelationship I0..*ElementThe 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..1code
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... (Choice of one) 1..1
...... observation 0..1Observation
...... regionOfInterest 0..1RegionOfInterest
...... observationMedia 0..1ObservationMedia
...... substanceAdministration 0..1SubstanceAdministration
...... supply 0..1Supply
...... procedure 0..1Procedure
...... encounter 0..1Encounter
...... organizer 0..1Organizer
...... act 0..1Act
.... entryRelationship:priorityPreference I0..*ElementThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
..... typeCode 1..1codeRequired Pattern: REFR
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1PriorityPreference
.... entryRelationship:indication I0..*ElementThe following entryRelationship represents the indication for the procedure.
..... typeCode 1..1codeRequired Pattern: RSON
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... observation 1..1Indication
.... entryRelationship:instruction I0..*ElementThe following entryRelationship captures any instructions associated with the planned procedure.
..... typeCode 1..1codeRequired Pattern: SUBJ
..... inversionInd 1..1booleanRequired Pattern: true
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1Instruction
.... entryRelationship:plannedCoverage I0..*Element
..... typeCode 1..1codeRequired Pattern: COMP
..... inversionInd 0..1boolean
..... contextConductionInd 1..1boolean
..... sequenceNumber 0..1INT
..... negationInd 0..1boolean
..... seperatableInd 0..1BL
..... act 1..1PlannedCoverage
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.moodCoderequiredPlanned moodCode (Act/Encounter/Procedure)
Procedure.templateId:primary.nullFlavorrequiredNullFlavor
Procedure.statusCoderequiredActStatus
Procedure.statusCode.nullFlavorrequiredNullFlavor
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage
Procedure.targetSiteCoderequiredBodySiteValueSet
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePathDetailsRequirements
1098-31977warningProcedure.codeThe 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-1errorProcedure.entryRelationshipOnly 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-1errorProcedure.entryRelationship:priorityPreferenceOnly 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-1errorProcedure.entryRelationship:indicationOnly 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-1errorProcedure.entryRelationship:instructionOnly 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-1errorProcedure.entryRelationship:plannedCoverageOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1