Clinical Document Architecture V2.1
2.1.0 - CI Build

Clinical Document Architecture V2.1, published by Health Level 7. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/cda-core-2.0/ and changes regularly. See the Directory of published versions

Logical Model: CDAR2.Procedure

Defining URL:http://hl7.org/fhir/cda/StructureDefinition/Procedure
Version:2.1.0
Name:CDAR2.Procedure
Title:Procedure (CDA Class)
Status:Active as of 2020-10-15T16:00:30+00:00
Definition:

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.

Publisher:Health Level 7
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/cda/StructureDefinition/Procedure

Formal Views of Profile Content

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

This structure is derived from Base

Summary

Mandatory: 0 element (19 nested mandatory elements)
Fixed Value: 9 elements

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CE
... approachSiteCode 0..*CD
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementproc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CE
... approachSiteCode 0..*CD
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementproc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format

This structure is derived from Base

Summary

Mandatory: 0 element (19 nested mandatory elements)
Fixed Value: 9 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CE
... approachSiteCode 0..*CD
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementproc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... templateId 0..*II
... negationInd 0..1boolean
... text 0..1ED
... statusCode 0..1CSBinding: ActStatus (required)
... effectiveTime 0..1IVL_TS
... priorityCode 0..1CEBinding: ActPriority (extensible)
... languageCode 0..1CSBinding: HumanLanguage (required)
... methodCode 0..*CE
... approachSiteCode 0..*CD
... targetSiteCode 0..*CD
... subject 0..1Element
.... typeCode 1..1codeBinding: ParticipationTargetSubject (required)
Fixed Value: SBJ
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... relatedSubject 1..1RelatedSubject
... specimen 0..*Element
.... typeCode 1..1codeBinding: ParticipationTargetDirect (required)
Fixed Value: SPC
.... specimenRole 1..1SpecimenRole
... performer 0..*Element
.... typeCode 1..1codeBinding: ParticipationPhysicalPerformer (required)
Fixed Value: PRF
.... time 0..1IVL_TS
.... modeCode 0..1CEBinding: ParticipationMode (extensible)
.... assignedEntity 1..1AssignedEntity
... author 0..*Author
... informant 0..*Element
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Element
.... typeCode 1..1codeBinding: ParticipationType (required)
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... time 0..1IVL_TS
.... awarenessCode 0..1CEBinding: TargetAwareness (extensible)
.... participantRole 1..1ParticipantRole
... entryRelationship I0..*Elementproc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... typeCode 1..1code
.... inversionInd 0..1boolean
.... contextConductionInd 1..1boolean
.... sequenceNumber 0..1INT
.... negationInd 0..1boolean
.... seperatableInd 0..1BL
.... (Choice of one) 1..1
..... observation 0..1Observation
..... regionOfInterest 0..1RegionOfInterest
..... observationMedia 0..1ObservationMedia
..... substanceAdministration 0..1SubstanceAdministration
..... supply 0..1Supply
..... procedure 0..1Procedure
..... encounter 0..1Encounter
..... organizer 0..1Organizer
..... act 0..1Act
... reference 0..*Element
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Element
.... typeCode 1..1codeBinding: ActRelationshipConditional (required)
Fixed Value: PRCN
.... criterion 1..1Criterion

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.specimen.typeCoderequiredFixed Value: SPC
Procedure.performer.typeCoderequiredFixed Value: PRF
Procedure.performer.modeCodeextensibleParticipationMode
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP
Procedure.participant.typeCoderequiredParticipationType
Procedure.participant.contextControlCoderequiredFixed Value: OP
Procedure.participant.awarenessCodeextensibleTargetAwareness
Procedure.precondition.typeCoderequiredFixed Value: PRCN

Constraints

IdPathDetailsRequirements
proc-er-1Procedure.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1