Clinical Document Architecture
2.0.1-sd - release

Clinical Document Architecture, published by Health Level 7. This guide is not an authorized publication; it is the continuous build for version 2.0.1-sd built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/CDA-core-sd/ and changes regularly. See the Directory of published versions

Logical Model: Procedure (CDA Class)

Official URL: http://hl7.org/cda/stds/core/StructureDefinition/Procedure Version: 2.0.1-sd
Active as of 2024-12-18 Computable Name: Procedure

A derivative of the RIM Procedure class, used for representing procedures.

Procedure.negationInd, when set to "true", is a positive assertion that the Procedure as a whole is negated. Some properties such as Procedure.id, Procedure.moodCode, and the participations are not affected. These properties always have the same meaning: i.e., the author remains the author of the negative Procedure. A procedure statement with negationInd is still a statement about the specific fact described by the Procedure. For instance, a negated "appendectomy performed" means that the author positively denies that there was ever an appendectomy performed, and that he takes the same responsibility for such statement and the same requirement to have evidence for such statement than if he had not used negation.

Usage:

Formal Views of Template Content

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

This structure is derived from InfrastructureRoot

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1 InfrastructureRoot XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
... id 0..* II
... code 0..1 CD
... @negationInd 0..1 bl
... text 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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 (Differential)

PathConformanceValueSet / CodeURI
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredXDocumentProcedureMood
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1 InfrastructureRoot XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @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
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 0..1 CD
... @negationInd 0..1 bl
... text 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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

PathConformanceValueSet / CodeURI
Procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredXDocumentProcedureMood
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
II-1errorProcedure.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1 InfrastructureRoot XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @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
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 0..1 CD
... @negationInd 0..1 bl
... text 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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

PathConformanceValueSet / CodeURI
Procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredXDocumentProcedureMood
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
II-1errorProcedure.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(2 nested mandatory elements)
Fixed: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from InfrastructureRoot

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1 InfrastructureRoot XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
... id 0..* II
... code 0..1 CD
... @negationInd 0..1 bl
... text 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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 (Differential)

PathConformanceValueSet / CodeURI
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredXDocumentProcedureMood
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1 InfrastructureRoot XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @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
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 0..1 CD
... @negationInd 0..1 bl
... text 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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

PathConformanceValueSet / CodeURI
Procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredXDocumentProcedureMood
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
II-1errorProcedure.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1 InfrastructureRoot XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
... @nullFlavor 0..1 cs Binding: CDANullFlavor (required)
... realmCode 0..* CS
... typeId C 0..1 II II-1: An II instance must have either a root or an nullFlavor.
.... @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
... @classCode 1..1 cs Binding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1 cs Binding: x_DocumentProcedureMood (required)
... id 0..* II
... sdtcCategory 0..* CD XML Namespace: urn:hl7-org:sdtc
XML: category (urn:hl7-org:sdtc)
... code 0..1 CD
... @negationInd 0..1 bl
... text 0..1 ED
... statusCode 0..1 CS Binding: ActStatus (required)
... effectiveTime 0..1 IVL_TS
... priorityCode 0..1 CE Binding: ActPriority (example)
... languageCode 0..1 CS Binding: AllLanguages (required)
... methodCode 0..* CE
... approachSiteCode 0..* CD
... targetSiteCode 0..* CD
... subject 0..1 Subject
... specimen 0..* Specimen
... performer 0..* Performer2
... author 0..* Author
... informant 0..* Informant
... participant 0..* Participant2
... entryRelationship 0..* EntryRelationship
... 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

PathConformanceValueSet / CodeURI
Procedure.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.typeId.nullFlavorrequiredCDANullFlavor
http://hl7.org/cda/stds/core/ValueSet/CDANullFlavor
from this IG
Procedure.classCoderequiredFixed Value: PROC
http://terminology.hl7.org/ValueSet/v3-ActClassProcedure
Procedure.moodCoderequiredXDocumentProcedureMood
http://terminology.hl7.org/ValueSet/v3-xDocumentProcedureMood
Procedure.statusCoderequiredActStatus
http://terminology.hl7.org/ValueSet/v3-ActStatus
Procedure.priorityCodeexampleActPriority
http://terminology.hl7.org/ValueSet/v3-ActPriority
Procedure.languageCoderequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
II-1errorProcedure.typeIdAn II instance must have either a root or an nullFlavor.
: root.exists() or nullFlavor.exists()

This structure is derived from InfrastructureRoot

Summary

Mandatory: 0 element(2 nested mandatory elements)
Fixed: 1 element

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel