Clinical Document Architecture V2.0.1
2.1.0-cibuild - CI Build

Clinical Document Architecture V2.0.1, published by Health Level 7. This is not an authorized publication; it is the continuous build for version 2.1.0-cibuild). This version is based on the current content of https://github.com/ahdis/cda-core-2.0/ and changes regularly. See the Directory of published versions

Logical Model: Procedure (CDA Class)

Official URL: http://hl7.org/fhir/cda/StructureDefinition/Procedure Version: 2.1.0-cibuild
Active as of 2022-11-02 Computable Name: CDAR2.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:

  • This Logical Model Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1BaseXML Namespace: urn:hl7-org:v3
Base for all types and resources
... @classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... id 0..*II
... code 0..1CD
... @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..*Specimen
... performer 0..*Performer2
... 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..*Participant2
... entryRelationship C0..*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..*Precondition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
proc-er-1errorProcedure.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CD
... 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..*Specimen
... performer 0..*Performer2
... 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..*Participant2
... entryRelationship C0..*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..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
proc-er-1errorProcedure.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CD
... 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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... 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..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementproc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... 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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
proc-er-1errorProcedure.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from Base

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 5 elements

Differential View

This structure is derived from Base

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1BaseXML Namespace: urn:hl7-org:v3
Base for all types and resources
... @classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... @moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... id 0..*II
... code 0..1CD
... @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..*Specimen
... performer 0..*Performer2
... 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..*Participant2
... entryRelationship C0..*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..*Precondition

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

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

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CD
... 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..*Specimen
... performer 0..*Performer2
... 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..*Participant2
... entryRelationship C0..*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..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
proc-er-1errorProcedure.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 1..1BaseBase for all types and resources
... classCode 1..1codeBinding: ActClassProcedure (required)
Fixed Value: PROC
... moodCode 1..1code
... realmCode 0..*CS
... templateId 0..*II
... code 0..1CD
... 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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... 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..*Specimen
... performer 0..*Performer2
... author 0..*Author
... informant 0..*Element
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1codeBinding: ParticipationInformationGenerator (required)
Fixed Value: INF
.... contextControlCode 1..1codeBinding: ContextControl (required)
Fixed Value: OP
.... assignedEntity 0..1AssignedEntity
.... relatedEntity 0..1RelatedEntity
... participant 0..*Participant2
... entryRelationship C0..*Elementproc-er-1: Only one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... 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
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... typeCode 1..1code
.... seperatableInd 0..1BL
.... externalAct 0..1ExternalAct
.... externalObservation 0..1ExternalObservation
.... externalProcedure 0..1ExternalProcedure
.... externalDocument 0..1ExternalDocument
... precondition 0..*Precondition

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.classCoderequiredFixed Value: PROC
Procedure.statusCoderequiredActStatus
Procedure.priorityCodeextensibleActPriority
Procedure.languageCoderequiredHumanLanguage (a valid code from http://terminology.hl7.org/CodeSystem/ietf3066)
Procedure.subject.typeCoderequiredFixed Value: SBJ
Procedure.subject.contextControlCoderequiredFixed Value: OP
Procedure.subject.awarenessCodeextensibleTargetAwareness
Procedure.informant.typeCoderequiredFixed Value: INF
Procedure.informant.contextControlCoderequiredFixed Value: OP

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
proc-er-1errorProcedure.entryRelationshipOnly one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer, and act
: (observation | regionOfInterest | observationMedia | substanceAdministration | supply | procedure | encounter | organizer | act).count() = 1

This structure is derived from Base

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 5 elements

 

Other representations of profile: CSV, Excel