1.3.6.1.4.1.19376.1.5.3.1.4.19

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Trial.gif Procedure Entry 1.3.6.1.4.1.19376.1.5.3.1.4.19

The procedure entry is used to record procedures that have occured, or which are planned for in the future.

Standards
CCD ASTM/HL7 Continuity of Care Document
Uses

See Templates using Procedure Entry

Specification
Procedure Entry Example
<procedure classCode='PROC' moodCode='EVN|INT'>
  <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>
  <templateId root='2.16.840.1.113883.10.20.1.29'/><!-- see text of section 0 -->
  <templateId root='2.16.840.1.113883.10.20.1.25'/><!-- see text of section 0 -->
  <id root='' extension=''/>
  <code code='' codeSystem='2.16.840.1.113883.5.4' codeSystemName='ActCode' />
  <text><reference value='#xxx'/></text>
  <statusCode code='completed|active|aborted|cancelled'/>
  <effectiveTime>
    <low value=''/>
    <high value=''/>
  </effectiveTime>
  <priorityCode code=''/>
  <approachSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
  <targetSiteCode code='' displayName='' codeSystem='' codeSystemName=''/>
  <author />
  <informant />
  <entryRelationship typeCode='COMP' inversionInd='true'>
    <act classCode='ACT' moodCode=''>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
  <entryRelationship typeCode='RSON'>
    <act classCode='ACT' moodCode='EVN'>
      <templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.4.1'/>
      <id root='' extension=''/>
    </act>
  </entryRelationship>
</procedure>


<procedure classCode='PROC' moodCode='EVN|INT'>

This element is a procedure. The classCode shall be 'PROC'. The moodCode may be INT to indicated a planned procedure or EVN, to describe a procedure that has already occurred.

<templateId root='1.3.6.1.4.1.19376.1.5.3.1.4.19'/>

The templateId indicates that this <procedure> entry conforms to the constraints of this content module. NOTE: When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29, and when in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

<id root=' ' extension=' '/>

This required element shall contain an identifier for the procedure. More than one procedure identifier may be present.

<code code=' ' displayName=' ' codeSystem=' ' codeSystemName=' ' />

This element shall be present, and should contain a code describing the type of procedure.

<text><reference value='#xxx'/></text>

The <text> element shall contain a reference to the narrative text describing the procedure.

<statusCode code='completed|active|aborted|cancelled'/>

The <statusCode> element shall be present when used to describe a procedure event. It shall have the value 'completed' for procedures that have been completed, and 'active' for procedures that are still in progress. Procedures that were stopped prior to completion shall use the value 'aborted', and procedures that were cancelled before being started shall use the value 'cancelled'.

<effectiveTime><low value=' '/><high value=' '/></effectiveTime>

This element should be present, and records the time at which the procedure occurred (in EVN mood), or the desired time of the procedure in INT mood.

<priorityCode code=' '/>

This element shall be present in INT mood when effectiveTime is not provided, it may be present in other moods. It indicates the priority of the procedure.

<approachSiteCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element may be present to indicate the procedure approach.

<targetSiteCode code=' ' displayName=' ' codeSystem=' ' codeSystemName=' '/>

This element may be present to indicate the target site of the procedure.

<entryRelationship typeCode='COMP' inversionInd='true'>

This element may be present to point the encounter in which the procedure was performed, and shall contain an internal reference to the encounter. See Internal References for more details.

<entryRelationship typeCode='RSON'>

A <procedure> act may indicate one or more reasons for the procedure. These reasons identify the concern that was the reason for the procedure via an Internal Reference to the concern. The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.