Generated Narrative: StructureDefinition PlannedProcedure Name Flags Card. Type Description & Constraints Procedure <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( should-text-ref-value, should-sdtcCategory, should-effectiveTime, should-author )">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 #xD; Slices for templateId 1..* II Slice: Unordered, Open by value:root, value:extension #xD; templateId:planned-proc 1..1 II #xD; @root 1..1 oid, uuid, ruid Required Pattern: 2.16.840.1.113883.10.20.22.4.41 #xD; @extension 1..1 st Required Pattern: 2022-06-01 #xD; @classCode 1..1 cs #xD; @moodCode 1..1 cs Binding: Planned moodCode (Act/Encounter/Procedure) (required) #xD; id 1..* II #xD; sdtcCategory 0..* CD Binding: US Core ServiceRequest Category Codes (preferred) #xD; code 1..1 CD 헨?헦?헖?헗?헜?: SDOH Interventions Binding: US Core Procedure Codes (preferred) Additional Bindings Purpose Documentation 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 #xD; text 0..1 ED SHOULD reference the portion of section narrative text corresponding to this entry #xD; reference <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R5/conformance-rules.html#constraints" title="This element has or is affected by constraints ( value-starts-octothorpe )">C 0..1 TEL Constraints: value-starts-octothorpe #xD; statusCode 1..1 CS #xD; @code 1..1 cs Fixed Value: active #xD; effectiveTime 0..1 IVL_TS The effectiveTime in a planned procedure represents the time that the procedure should occur. #xD; 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. #xD; 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) #xD; performer 0..* Performer2 The clinician who is expected to perform the procedure could be identified using procedure/performer. #xD; author 0..1 AuthorParticipation The author in a planned procedure represents the clinician who is requesting or planning the procedure. #xD; Slices for entryRelationship 0..* EntryRelationship Slice: Unordered, Open by profile:act, profile:observation #xD; entryRelationship:priorityPreference 0..* EntryRelationship The following entryRelationship represents the priority that a patient or a provider places on the procedure. #xD; @typeCode 1..1 cs Fixed Value: REFR #xD; observation 1..1 PriorityPreference #xD; entryRelationship:indication 0..* EntryRelationship The following entryRelationship represents the indication for the procedure. #xD; @typeCode 1..1 cs Fixed Value: RSON #xD; observation 1..1 Indication #xD; entryRelationship:instruction 0..* EntryRelationship The following entryRelationship captures any instructions associated with the planned procedure. #xD; @typeCode 1..1 cs Fixed Value: SUBJ #xD; @inversionInd 1..1 bl Fixed Value: true #xD; observation 1..1 InstructionObservation #xD; entryRelationship:coverage 0..* EntryRelationship The following entryRelationship represents the insurance coverage the patient may have for the procedure. #xD; @typeCode 1..1 cs Fixed Value: COMP #xD; act 1..1 PlannedCoverage #xD; 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. #xD; @typeCode 1..1 cs Fixed Value: RSON #xD; observation 1..1 AssessmentScaleObservation #xD; 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. #xD; @typeCode 1..1 cs Fixed Value: RSON #xD; act 1..1 EntryReference #xD; Documentation for this format
HL7 International - Structured Documents
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](StructureDefinition-AssessmentScaleObservation.html), [EntryReference](StructureDefinition-EntryReference.html), [Indication](StructureDefinition-Indication.html), [InstructionObservation](StructureDefinition-InstructionObservation.html), [PlannedCoverage](StructureDefinition-PlannedCoverage.html), [PriorityPreference](StructureDefinition-PriorityPreference.html)
Defines the basic properties of every data value. This is an abstract type, meaning that no value can be just a data value without belonging to any concrete type. Every concrete type is a specialization of this general abstract DataValue type.
If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
When valued in an instance, this attribute signals the imposition of realm-specific constraints. The value of this attribute identifies the realm in question
When valued in an instance, this attribute signals the imposition of constraints defined in an HL7-specified message type. This might be a common type (also known as CMET in the messaging communication environment), or content included within a wrapper. The value of this attribute provides a unique identifier for the type in question.
An II instance must have either a root or an nullFlavor.
A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Identifies the type as an HL7 Registered model
A character string as a unique identifier within the scope of the identifier root.
When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6 STATIC) (CONF:4515-8568).
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).
SHALL contain at least one [1..*] id (CONF:4515-8571).
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 .
If the Planned Intervention Procedure is a Social Determinant of Health Planned Intervention Procedure, the procedure code **SHOULD** be selected from ValueSet [Social Determinant of Health Service Request](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1196.790/expansion) **DYNAMIC** (CONF:4515-32993).
For Social Determinant of Planned Intervention Procedure
SHOULD reference the portion of section narrative text corresponding to this entry
Indicates whether the raw byte data is compressed, and what compression algorithm was used.
The integrity check is a short binary value representing a cryptographically strong checksum that is calculated over the binary data. The purpose of this property, when communicated with a reference is for anyone to validate later whether the reference still resolved to the same data that the reference resolved to when the encapsulated data value with reference was created.
Specifies the algorithm used to compute the integrityCheck value. The cryptographically strong checksum algorithm Secure Hash Algorithm-1 (SHA-1) is currently the industry standard. It has superseded the MD5 algorithm only a couple of years ago, when certain flaws in the security of MD5 were discovered. Currently the SHA-1 hash algorithm is the default choice for the integrity check algorithm. Note that SHA-256 is also entering widespread usage.
For character based information the language property specifies the human language of the text.
Identifies the type of the encapsulated data and identifies a method to interpret or render the data.
Allows for mixed text content. If @representation='B64', this SHALL be a base64binary string.
Data that is primarily intended for human interpretation or for further machine processing is outside the scope of HL7. This includes unformatted or formatted written language, multimedia data, or structured information as defined by a different standard (e.g., XML-signatures.)
This element is represented in XML as textual content. The actual name "xmlText" will not appear in a CDA instance.
A telecommunication address (TEL), such as a URL for HTTP or FTP, which will resolve to precisely the same binary data that could as well have been provided as inline data.
If reference/@value is present, it SHALL begin with a '#' and SHALL point to its corresponding narrative
value.exists() implies value.startsWith('#')
An abbreviated rendition of the full data. A thumbnail requires significantly fewer resources than the full data, while still maintaining some distinctive similarity with the full data. A thumbnail is typically used with by-reference encapsulated data. It allows a user to select data more efficiently before actually downloading through the reference.
SHALL contain exactly one [1..1] statusCode (CONF:4515-30446).
The plain code symbol defined by the code system. For example, "784.0" is the code symbol of the ICD-9 code "784.0" for headache.
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).
Specifies the code system that defines the code.
If applicable, a version descriptor defined specifically for the given code system.
A name or title for the code, under which the sending system shows the code value to its users.
The valueSet extension adds an attribute for elements with a CD dataType which indicates the particular value set constraining the coded concept.
The valueSetVersion extension adds an attribute for elements with a CD dataType which indicates the version of the particular value set constraining the coded concept.
The text or phrase used as the basis for the coding.
Specifies additional codes that increase the specificity of the the primary code.
A set of other concept descriptors that translate this concept descriptor into other code systems.
The effectiveTime in a planned procedure represents the time that the procedure should occur.
SHOULD contain zero or one [0..1] effectiveTime (CONF:4515-30447).
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.
Drawn from concept domain ProcedureMethod
MAY contain zero or more [0..*] methodCode (CONF:4515-31980).
The targetSiteCode is used to identify the part of the body of concern for the planned procedure.
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).
The clinician who is expected to perform the procedure could be identified using procedure/performer.
MAY contain zero or more [0..*] performer (CONF:4515-30449).
The author in a planned procedure represents the clinician who is requesting or planning the procedure.
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).
MAY contain zero or more [0..*] entryRelationship (CONF:4515-32996) such that it
The following entryRelationship represents the priority that a patient or a provider places on the procedure.
MAY contain zero or more [0..*] entryRelationship (CONF:4515-31079) such that it
SHALL contain exactly one [1..1] @typeCode="REFR" Refers to (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31080).
The entryRelationship.inversionInd can be set to "true" to indicate that the relationship should be interpreted as if the roles of the source and target entries were reversed.
The entryRelationship.contextConductionInd differs from the otherwise common use of this attribute in that in all other cases where this attribute is used, the value is fixed at "true", whereas here the value is defaulted to "true", and can be changed to "false" when referencing an entry in the same document. Setting the context conduction to false when referencing an entry in the same document keeps clear the fact that the referenced object retains its original context.
SHALL contain exactly one [1..1] Priority Preference (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.143) (CONF:4515-31081).
The following entryRelationship represents the indication for the procedure.
MAY contain zero or more [0..*] entryRelationship (CONF:4515-31982) such that it
SHALL contain exactly one [1..1] @typeCode="RSON" Has Reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31983).
The following entryRelationship captures any instructions associated with the planned procedure.
MAY contain zero or more [0..*] entryRelationship (CONF:4515-31985) such that it
SHALL contain exactly one [1..1] @typeCode="SUBJ" Has Subject (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-31986).
SHALL contain exactly one [1..1] @inversionInd="true" True (CONF:4515-31987).
The following entryRelationship represents the insurance coverage the patient may have for the procedure.
MAY contain zero or more [0..*] entryRelationship (CONF:4515-31990) such that it
SHALL contain exactly one [1..1] @typeCode="COMP" Has component (CONF:4515-31991).
SHALL contain exactly one [1..1] Planned Coverage (identifier: urn:oid:2.16.840.1.113883.10.20.22.4.129) (CONF:4515-31992).
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.
MAY contain zero or more [0..*] entryRelationship (CONF:4515-32994) such that it
SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:4515-32998).
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).
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.
SHALL contain exactly one [1..1] @typeCode="RSON" Has reason (CONF:4515-32999).