Consolidated CDA (C-CDA)
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Consolidated CDA (C-CDA), published by Health Level Seven. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-ccda/ and changes regularly. See the Directory of published versions

Logical Model: PlannedProcedure - Detailed Descriptions

Draft as of 2024-12-19

Definitions for the PlannedProcedure logical model.

Guidance on how to interpret the contents of this table can be found here

0. Procedure
Logical ContainerClinicalDocument (CDA Class)
ValidationInstance of this type are validated by templateId
XML FormatIn the XML format, this property has the namespace urn:hl7-org:v3.
Invariantsshould-text-ref-value: SHOULD contain text/reference/@value (text.reference.value.exists())
should-sdtcCategory: SHOULD contain sdtcCategory (sdtcCategory.exists())
should-effectiveTime: SHOULD contain effectiveTime (effectiveTime.exists())
should-author: SHOULD contain author (author.exists())
2. Procedure.templateId
Control1..?
SlicingThis element introduces a set of slices on Procedure.templateId. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ root
  • value @ extension
  • 4. Procedure.templateId:planned-proc
    Slice Nameplanned-proc
    Control1..1
    6. Procedure.templateId:planned-proc.root
    Control1..?
    Pattern Value2.16.840.1.113883.10.20.22.4.41
    8. Procedure.templateId:planned-proc.extension
    Control1..?
    Pattern Value2022-06-01
    10. Procedure.classCode
    Comments

    SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4515-8568).

    12. Procedure.moodCode
    Comments

    SHALL contain exactly one [1..1] @moodCode, which SHALL be selected from ValueSet Planned moodCode (Act/Encounter/Procedure) urn:oid:2.16.840.1.113883.11.20.9.23 STATIC 2011-09-30 (CONF:4515-8569).

    BindingThe codes SHALL be taken from Planned moodCode (Act/Encounter/Procedure) .
    (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.9.23)
    14. Procedure.id
    Comments

    SHALL contain at least one [1..*] id (CONF:4515-8571).

    Control1..?
    16. Procedure.sdtcCategory
    Control0..1
    BindingThe codes SHOULD be taken from US Core ServiceRequest Category Codes
    (preferred to http://hl7.org/fhir/us/core/ValueSet/us-core-servicerequest-category)
    18. Procedure.code
    Short𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Comments

    This code SHALL contain exactly one [1..1] @code, which SHOULD be selected from ValueSet US Core Procedure Codes urn:oid:2.16.840.1.113883.4.642.40.48.31 .

    Control1..?
    BindingThe codes SHOULD be taken from US Core Procedure Codes
    (preferred to http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code)
    20. Procedure.text
    ShortSHOULD reference the portion of section narrative text corresponding to this entry
    22. Procedure.text.reference
    Invariantsvalue-starts-octothorpe: If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative (value.exists() implies value.startsWith('#'))
    24. Procedure.statusCode
    Comments

    SHALL contain exactly one [1..1] statusCode (CONF:4515-30446).

    Control1..?
    26. Procedure.statusCode.code
    Comments

    This statusCode SHALL contain exactly one [1..1] @code="active" Active (CodeSystem: HL7ActStatus urn:oid:2.16.840.1.113883.5.14) (CONF:4515-31978).

    Control1..?
    Fixed Valueactive
    28. Procedure.effectiveTime
    ShortThe effectiveTime in a planned procedure represents the time that the procedure should occur.
    Comments

    SHOULD contain zero or one [0..1] effectiveTime (CONF:4515-30447).

    30. Procedure.methodCode
    ShortIn 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.
    Comments

    MAY contain zero or more [0..*] methodCode (CONF:4515-31980).

    32. Procedure.targetSiteCode
    ShortThe targetSiteCode is used to identify the part of the body of concern for the planned procedure.
    Comments

    MAY contain zero or more [0..*] targetSiteCode, which SHALL be selected from ValueSet Body Site Value Set urn:oid:2.16.840.1.113883.3.88.12.3221.8.9 DYNAMIC (CONF:4515-31981).

    BindingThe codes SHALL be taken from Body Site Value Set .
    (required to http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.3221.8.9)
    34. Procedure.performer
    ShortThe clinician who is expected to perform the procedure could be identified using procedure/performer.
    Comments

    MAY contain zero or more [0..*] performer (CONF:4515-30449).

    36. Procedure.author
    ShortThe author in a planned procedure represents the clinician who is requesting or planning the procedure.
    Comments

    SHOULD contain zero or one [0..1] Author Participation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.119) (CONF:4515-31979).

    Control0..1
    Typehttp://hl7.org/cda/stds/core/StructureDefinition/Author(Author Participation)
    38. Procedure.entryRelationship
    Comments

    MAY contain zero or more [0..*] entryRelationship (CONF:4515-32996) such that it

    SlicingThis element introduces a set of slices on Procedure.entryRelationship. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ act
    • profile @ observation
    • 40. Procedure.entryRelationship:priorityPreference
      Slice NamepriorityPreference
      ShortThe following entryRelationship represents the priority that a patient or a provider places on the procedure.
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-31079) such that it

      Control0..*
      42. Procedure.entryRelationship:priorityPreference.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31080).

      Fixed ValueREFR
      44. Procedure.entryRelationship:priorityPreference.observation
      Comments

      SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:4515-31081).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Priority Preference)
      46. Procedure.entryRelationship:indication
      Slice Nameindication
      ShortThe following entryRelationship represents the indication for the procedure.
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-31982) such that it

      Control0..*
      48. Procedure.entryRelationship:indication.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31983).

      Fixed ValueRSON
      50. Procedure.entryRelationship:indication.observation
      Comments

      SHALL contain exactly one [1..1] Indication (identifier: urn:hl7ii:2.16.840.1.113883.10.20.22.4.19:2014-06-09) (CONF:4515-31984).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Indication)
      52. Procedure.entryRelationship:instruction
      Slice Nameinstruction
      ShortThe following entryRelationship captures any instructions associated with the planned procedure.
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-31985) such that it

      Control0..*
      54. Procedure.entryRelationship:instruction.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31986).

      Fixed ValueSUBJ
      56. Procedure.entryRelationship:instruction.inversionInd
      Comments

      SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:4515-31987).

      Control1..?
      Fixed Valuetrue
      58. Procedure.entryRelationship:instruction.observation
      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Instruction Observation)
      60. Procedure.entryRelationship:coverage
      Slice Namecoverage
      ShortThe following entryRelationship represents the insurance coverage the patient may have for the procedure.
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-31990) such that it

      Control0..*
      62. Procedure.entryRelationship:coverage.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:4515-31991).

      Fixed ValueCOMP
      64. Procedure.entryRelationship:coverage.act
      Comments

      SHALL contain exactly one [1..1] Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:4515-31992).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act(Planned Coverage)
      66. Procedure.entryRelationship:assessmentScale
      Slice NameassessmentScale
      ShortWhen an Assessment Scale Observation is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Assessment scale **MAY** contain Assessment Scale observations that represent LOINC question and answer pairs from SDOH screening instruments.
      Comments

      MAY contain zero or more [0..*] entryRelationship (CONF:4515-32994) such that it

      Control0..*
      68. Procedure.entryRelationship:assessmentScale.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-32998).

      Fixed ValueRSON
      70. Procedure.entryRelationship:assessmentScale.observation
      Comments

      SHALL contain exactly one [1..1] Assessment Scale Observation (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.69) (CONF:4515-32995).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Observation(Assessment Scale Observation)
      72. Procedure.entryRelationship:entryReference
      Slice NameentryReference
      ShortWhen an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant of Health procedure, that Entry Reference **MAY** refer to Assessment Scale Observation in the same document that represent LOINC question and answer pairs from SDOH screening instruments.
      Control0..*
      74. Procedure.entryRelationship:entryReference.typeCode
      Comments

      SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CONF:4515-32999).

      Fixed ValueRSON
      76. Procedure.entryRelationship:entryReference.act
      Comments

      SHALL contain exactly one [1..1] Entry Reference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.122) (CONF:4515-32997).

      Control1..?
      Typehttp://hl7.org/cda/stds/core/StructureDefinition/Act(Entry Reference)