Consolidated CDA (C-CDA)
4.0.0 - STU4 United States of America flag

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 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: Planned Procedure

Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/PlannedProcedure Version: 4.0.0
Draft as of 2025-10-02 Computable Name: PlannedProcedure
Other Identifiers: urn:ietf:rfc:3986#Uniform Resource Identifier (URI)#urn:hl7ii:2.16.840.1.113883.10.20.22.4.41:2022-06-01

This template is used to represent ordered procedures for a patient. A procedure is an activity that is performed on, with, or for a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise, etc. Procedures may be performed by a healthcare professional, a service provider, a friend or relative or in some cases by the patient themselves.

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".

Templates Used

Although open templates may contain any valid CDA content, the following templates are specifically called out by this template:

Optional EntryRelationships: AssessmentScaleObservation, EntryReference, Indication, InstructionObservation, PlannedCoverage, PriorityPreference

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 3.0.0:

  • New Content

    • Formal Views of Template Content

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

    This structure is derived from Procedure

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:planned-proc 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs
    ... @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) . (required)
    ... sdtcCategory 0..* CD Binding: US Core ServiceRequest Category Codes (preferred)
    ... code 1..1 CD 𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Binding: US Core Procedure Codes (preferred)
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Service Requests . Preferred
    For Social Determinant of Planned Intervention Procedure
    Common LOINC Lab Codes . Preferred
    Common Lab Tests
    Radiology Procedures (LOINC) . Preferred
    Radiology
    Clinical Tests . Preferred
    Clinical Test
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... statusCode 1..1 CS
    .... @code 1..1 cs Fixed Value: 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..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure.
    ..... @typeCode 1..1 cs Fixed Value: REFR
    ..... observation 1..1 PriorityPreference
    .... entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure.
    ..... @typeCode 1..1 cs Fixed Value: RSON
    ..... observation 1..1 Indication
    .... entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure.
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... observation 1..1 InstructionObservation
    .... entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure.
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... act 1..1 PlannedCoverage
    .... entryRelationship:assessmentScale 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: RSON
    ..... observation 1..1 AssessmentScaleObservation
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: RSON
    ..... act 1..1 EntryReference

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Procedure.moodCode Base required Planned moodCode (Act/Encounter/Procedure) . 📦20240606 VSAC v0.23
    Procedure.sdtcCategory Base preferred US Core ServiceRequest Category Codes 📦8.0.0 US Core v8.0
    Procedure.code Base preferred US Core Procedure Codes 📦8.0.0 US Core v8.0
    Procedure.targetSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    should-author warning Procedure SHOULD contain author author.exists()
    should-effectiveTime warning Procedure SHOULD contain effectiveTime effectiveTime.exists()
    should-sdtcCategory warning Procedure SHOULD contain sdtcCategory sdtcCategory.exists()
    should-text-ref-value warning Procedure SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Procedure.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:planned-proc 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs Binding: ActClassProcedure (required)
    Fixed Value: PROC
    ... @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) . (required)
    ... id 1..* II
    ... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    XML: category (urn:hl7-org:sdtc)
    Binding: US Core ServiceRequest Category Codes (preferred)
    ... code 1..1 CD 𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Binding: US Core Procedure Codes (preferred)
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Service Requests . Preferred
    For Social Determinant of Planned Intervention Procedure
    Common LOINC Lab Codes . Preferred
    Common Lab Tests
    Radiology Procedures (LOINC) . Preferred
    Radiology
    Clinical Tests . Preferred
    Clinical Test
    ... @negationInd 0..1 bl
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: active
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    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 (example)
    ... languageCode 0..1 CS Binding: AllLanguages (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 Subject
    ... 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..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: REFR
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 PriorityPreference
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 Indication
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 InstructionObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: COMP
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 PlannedCoverage
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:assessmentScale 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Procedure.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.templateId:planned-proc.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.classCode Base required ActClassProcedure 📦3.0.0 THO v6.5
    Procedure.moodCode Base required Planned moodCode (Act/Encounter/Procedure) . 📦20240606 VSAC v0.23
    Procedure.sdtcCategory Base preferred US Core ServiceRequest Category Codes 📦8.0.0 US Core v8.0
    Procedure.code Base preferred US Core Procedure Codes 📦8.0.0 US Core v8.0
    Procedure.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Procedure.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Procedure.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Procedure.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Procedure.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Procedure.targetSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    Procedure.entryRelationship:priorityPreference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:coverage.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:assessmentScale.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Procedure.typeId, Procedure.entryRelationship:priorityPreference.typeId, Procedure.entryRelationship:indication.typeId, Procedure.entryRelationship:instruction.typeId, Procedure.entryRelationship:coverage.typeId, Procedure.entryRelationship:assessmentScale.typeId, Procedure.entryRelationship:entryReference.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-author warning Procedure SHOULD contain author author.exists()
    should-effectiveTime warning Procedure SHOULD contain effectiveTime effectiveTime.exists()
    should-sdtcCategory warning Procedure SHOULD contain sdtcCategory sdtcCategory.exists()
    should-text-ref-value warning Procedure SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Procedure.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:planned-proc 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs Binding: ActClassProcedure (required)
    Fixed Value: PROC
    ... @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) . (required)
    ... id 1..* II
    ... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    XML: category (urn:hl7-org:sdtc)
    Binding: US Core ServiceRequest Category Codes (preferred)
    ... code 1..1 CD 𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Binding: US Core Procedure Codes (preferred)
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Service Requests . Preferred
    For Social Determinant of Planned Intervention Procedure
    Common LOINC Lab Codes . Preferred
    Common Lab Tests
    Radiology Procedures (LOINC) . Preferred
    Radiology
    Clinical Tests . Preferred
    Clinical Test
    ... @negationInd 0..1 bl
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: active
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    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 (example)
    ... languageCode 0..1 CS Binding: AllLanguages (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 Subject
    ... 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..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: REFR
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 PriorityPreference
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 Indication
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 InstructionObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: COMP
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 PlannedCoverage
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:assessmentScale 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Procedure.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.templateId:planned-proc.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.classCode Base required ActClassProcedure 📦3.0.0 THO v6.5
    Procedure.moodCode Base required Planned moodCode (Act/Encounter/Procedure) . 📦20240606 VSAC v0.23
    Procedure.sdtcCategory Base preferred US Core ServiceRequest Category Codes 📦8.0.0 US Core v8.0
    Procedure.code Base preferred US Core Procedure Codes 📦8.0.0 US Core v8.0
    Procedure.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Procedure.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Procedure.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Procedure.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Procedure.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Procedure.targetSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    Procedure.entryRelationship:priorityPreference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:coverage.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:assessmentScale.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Procedure.typeId, Procedure.entryRelationship:priorityPreference.typeId, Procedure.entryRelationship:indication.typeId, Procedure.entryRelationship:instruction.typeId, Procedure.entryRelationship:coverage.typeId, Procedure.entryRelationship:assessmentScale.typeId, Procedure.entryRelationship:entryReference.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-author warning Procedure SHOULD contain author author.exists()
    should-effectiveTime warning Procedure SHOULD contain effectiveTime effectiveTime.exists()
    should-sdtcCategory warning Procedure SHOULD contain sdtcCategory sdtcCategory.exists()
    should-text-ref-value warning Procedure SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Procedure.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')

    Differential View

    This structure is derived from Procedure

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:planned-proc 1..1 II
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs
    ... @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) . (required)
    ... sdtcCategory 0..* CD Binding: US Core ServiceRequest Category Codes (preferred)
    ... code 1..1 CD 𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Binding: US Core Procedure Codes (preferred)
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Service Requests . Preferred
    For Social Determinant of Planned Intervention Procedure
    Common LOINC Lab Codes . Preferred
    Common Lab Tests
    Radiology Procedures (LOINC) . Preferred
    Radiology
    Clinical Tests . Preferred
    Clinical Test
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    ... statusCode 1..1 CS
    .... @code 1..1 cs Fixed Value: 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..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure.
    ..... @typeCode 1..1 cs Fixed Value: REFR
    ..... observation 1..1 PriorityPreference
    .... entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure.
    ..... @typeCode 1..1 cs Fixed Value: RSON
    ..... observation 1..1 Indication
    .... entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure.
    ..... @typeCode 1..1 cs Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... observation 1..1 InstructionObservation
    .... entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure.
    ..... @typeCode 1..1 cs Fixed Value: COMP
    ..... act 1..1 PlannedCoverage
    .... entryRelationship:assessmentScale 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: RSON
    ..... observation 1..1 AssessmentScaleObservation
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @typeCode 1..1 cs Fixed Value: RSON
    ..... act 1..1 EntryReference

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    Procedure.moodCode Base required Planned moodCode (Act/Encounter/Procedure) . 📦20240606 VSAC v0.23
    Procedure.sdtcCategory Base preferred US Core ServiceRequest Category Codes 📦8.0.0 US Core v8.0
    Procedure.code Base preferred US Core Procedure Codes 📦8.0.0 US Core v8.0
    Procedure.targetSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23

    Constraints

    Id Grade Path(s) Description Expression
    should-author warning Procedure SHOULD contain author author.exists()
    should-effectiveTime warning Procedure SHOULD contain effectiveTime effectiveTime.exists()
    should-sdtcCategory warning Procedure SHOULD contain sdtcCategory sdtcCategory.exists()
    should-text-ref-value warning Procedure SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Procedure.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:planned-proc 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs Binding: ActClassProcedure (required)
    Fixed Value: PROC
    ... @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) . (required)
    ... id 1..* II
    ... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    XML: category (urn:hl7-org:sdtc)
    Binding: US Core ServiceRequest Category Codes (preferred)
    ... code 1..1 CD 𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Binding: US Core Procedure Codes (preferred)
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Service Requests . Preferred
    For Social Determinant of Planned Intervention Procedure
    Common LOINC Lab Codes . Preferred
    Common Lab Tests
    Radiology Procedures (LOINC) . Preferred
    Radiology
    Clinical Tests . Preferred
    Clinical Test
    ... @negationInd 0..1 bl
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: active
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    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 (example)
    ... languageCode 0..1 CS Binding: AllLanguages (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 Subject
    ... 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..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: REFR
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 PriorityPreference
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 Indication
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 InstructionObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: COMP
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 PlannedCoverage
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:assessmentScale 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Procedure.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.templateId:planned-proc.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.classCode Base required ActClassProcedure 📦3.0.0 THO v6.5
    Procedure.moodCode Base required Planned moodCode (Act/Encounter/Procedure) . 📦20240606 VSAC v0.23
    Procedure.sdtcCategory Base preferred US Core ServiceRequest Category Codes 📦8.0.0 US Core v8.0
    Procedure.code Base preferred US Core Procedure Codes 📦8.0.0 US Core v8.0
    Procedure.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Procedure.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Procedure.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Procedure.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Procedure.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Procedure.targetSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    Procedure.entryRelationship:priorityPreference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:coverage.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:assessmentScale.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Procedure.typeId, Procedure.entryRelationship:priorityPreference.typeId, Procedure.entryRelationship:indication.typeId, Procedure.entryRelationship:instruction.typeId, Procedure.entryRelationship:coverage.typeId, Procedure.entryRelationship:assessmentScale.typeId, Procedure.entryRelationship:entryReference.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-author warning Procedure SHOULD contain author author.exists()
    should-effectiveTime warning Procedure SHOULD contain effectiveTime effectiveTime.exists()
    should-sdtcCategory warning Procedure SHOULD contain sdtcCategory sdtcCategory.exists()
    should-text-ref-value warning Procedure SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Procedure.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. Procedure C 1..1 Procedure XML Namespace: urn:hl7-org:v3
    Base for all types and resources
    Instance of this type are validated by templateId
    Logical Container: ClinicalDocument (CDA Class)
    Constraints: should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author
    ... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ... realmCode 0..* CS
    ... typeId C 0..1 II Constraints: II-1
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @assigningAuthorityName 0..1 st
    .... @displayable 0..1 bl
    .... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    .... @extension 1..1 st
    ... Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension
    .... templateId:planned-proc 1..1 II
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... @assigningAuthorityName 0..1 st
    ..... @displayable 0..1 bl
    ..... @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41
    ..... @extension 1..1 st Required Pattern: 2022-06-01
    ... @classCode 1..1 cs Binding: ActClassProcedure (required)
    Fixed Value: PROC
    ... @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) . (required)
    ... id 1..* II
    ... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
    XML: category (urn:hl7-org:sdtc)
    Binding: US Core ServiceRequest Category Codes (preferred)
    ... code 1..1 CD 𝗨𝗦𝗖𝗗𝗜: SDOH Interventions
    Binding: US Core Procedure Codes (preferred)
    Additional BindingsPurposeDocumentation
    Social Determinants of Health Service Requests . Preferred
    For Social Determinant of Planned Intervention Procedure
    Common LOINC Lab Codes . Preferred
    Common Lab Tests
    Radiology Procedures (LOINC) . Preferred
    Radiology
    Clinical Tests . Preferred
    Clinical Test
    ... @negationInd 0..1 bl
    ... text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @compression 0..1 cs Binding: CDACompressionAlgorithm (required)
    .... @integrityCheck 0..1 bin
    .... @integrityCheckAlgorithm 0..1 cs Binding: IntegrityCheckAlgorithm (2.0.0) (required)
    .... @language 0..1 cs
    .... @mediaType 0..1 cs Binding: MediaType (example)
    .... @representation 0..1 cs Binding: CDABinaryDataEncoding (required)
    .... xmlText 0..1 st Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
    .... reference C 0..1 TEL Constraints: value-starts-octothorpe
    .... thumbnail 0..1 ED
    ... statusCode 1..1 CS Binding: ActStatus (required)
    .... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    .... @code 1..1 cs Fixed Value: active
    .... @sdtcValueSet 0..1 oid XML Namespace: urn:hl7-org:sdtc
    XML: valueSet (urn:hl7-org:sdtc)
    .... @sdtcValueSetVersion 0..1 st XML Namespace: urn:hl7-org:sdtc
    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 (example)
    ... languageCode 0..1 CS Binding: AllLanguages (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 Subject
    ... 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..* Informant
    ... participant 0..* Participant2
    ... Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation
    .... entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: REFR
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 PriorityPreference
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 Indication
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: SUBJ
    ..... @inversionInd 1..1 bl Fixed Value: true
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 InstructionObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: COMP
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 PlannedCoverage
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:assessmentScale 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 0..1 Act
    ..... encounter 0..1 Encounter
    ..... observation 1..1 AssessmentScaleObservation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    .... entryRelationship:entryReference 0..* EntryRelationship When 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.
    ..... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ..... realmCode 0..* CS
    ..... typeId C 0..1 II Constraints: II-1
    ...... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
    ...... @assigningAuthorityName 0..1 st
    ...... @displayable 0..1 bl
    ...... @root 1..1 oid, uuid, ruid Fixed Value: 2.16.840.1.113883.1.3
    ...... @extension 1..1 st
    ..... templateId 0..* II
    ..... @typeCode 1..1 cs Binding: x_ActRelationshipEntryRelationship (required)
    Fixed Value: RSON
    ..... @inversionInd 0..1 bl
    ..... @contextConductionInd 0..1 bl
    ..... @negationInd 0..1 bl
    ..... sequenceNumber 0..1 INT
    ..... seperatableInd 0..1 BL
    ..... act 1..1 EntryReference
    ..... encounter 0..1 Encounter
    ..... observation 0..1 Observation
    ..... observationMedia 0..1 ObservationMedia
    ..... organizer 0..1 Organizer
    ..... procedure 0..1 Procedure
    ..... regionOfInterest 0..1 RegionOfInterest
    ..... substanceAdministration 0..1 SubstanceAdministration
    ..... supply 0..1 Supply
    ... reference 0..* Reference
    ... precondition 0..* Precondition
    ... sdtcPrecondition2 0..* Precondition2 XML Namespace: urn:hl7-org:sdtc
    XML: precondition2 (urn:hl7-org:sdtc)
    ... sdtcInFulfillmentOf1 0..* InFulfillmentOf1 XML Namespace: urn:hl7-org:sdtc
    XML: inFulfillmentOf1 (urn:hl7-org:sdtc)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    Procedure.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.templateId:planned-proc.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.classCode Base required ActClassProcedure 📦3.0.0 THO v6.5
    Procedure.moodCode Base required Planned moodCode (Act/Encounter/Procedure) . 📦20240606 VSAC v0.23
    Procedure.sdtcCategory Base preferred US Core ServiceRequest Category Codes 📦8.0.0 US Core v8.0
    Procedure.code Base preferred US Core Procedure Codes 📦8.0.0 US Core v8.0
    Procedure.text.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.compression Base required CDACompressionAlgorithm 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.text.integrityCheckAlgorithm Base required IntegrityCheckAlgorithm 📍2.0.0 THO v5.2
    Procedure.text.mediaType Base example MediaType 📦3.0.0 THO v6.5
    Procedure.text.representation Base required CDABinaryDataEncoding 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.statusCode Base required ActStatus 📦3.0.0 THO v6.5
    Procedure.statusCode.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.priorityCode Base example ActPriority 📦3.0.0 THO v6.5
    Procedure.languageCode Base required All Languages 📦5.0.0 FHIR Std.
    Procedure.targetSiteCode Base required Body Site Value Set . 📦20240606 VSAC v0.23
    Procedure.entryRelationship:priorityPreference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:priorityPreference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:indication.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:indication.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:instruction.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:instruction.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:coverage.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:coverage.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:assessmentScale.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:assessmentScale.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5
    Procedure.entryRelationship:entryReference.​nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeId.nullFlavor Base required CDANullFlavor 📦2.0.1-sd Clinical Document Architecture v2.0
    Procedure.entryRelationship:entryReference.​typeCode Base required x_ActRelationshipEntryRelationship 📦3.0.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    II-1 error Procedure.typeId, Procedure.entryRelationship:priorityPreference.typeId, Procedure.entryRelationship:indication.typeId, Procedure.entryRelationship:instruction.typeId, Procedure.entryRelationship:coverage.typeId, Procedure.entryRelationship:assessmentScale.typeId, Procedure.entryRelationship:entryReference.typeId An II instance must have either a root or an nullFlavor. root.exists() or nullFlavor.exists()
    should-author warning Procedure SHOULD contain author author.exists()
    should-effectiveTime warning Procedure SHOULD contain effectiveTime effectiveTime.exists()
    should-sdtcCategory warning Procedure SHOULD contain sdtcCategory sdtcCategory.exists()
    should-text-ref-value warning Procedure SHOULD contain text/reference/@value text.reference.value.exists()
    value-starts-octothorpe error Procedure.text.reference If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative value.exists() implies value.startsWith('#')

     

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