FHIR Server FHIR Server Version n/a

Resource StructureDefinition/FHIR Server from package hl7.cda.us.ccda#current (1594 ms)

Package

hl7.cda.us.ccda

Type

StructureDefinition

FHIR Version

Source

http://hl7.org/cda/us/ccda/https://build.fhir.org/ig/HL7/CDA-ccda/StructureDefinition-ProcedureNote.html

Url

http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureNote

Version

4.0.0-ballot

Status

active

Date

2024-12-11T22:59:59+00:00

Name

ProcedureNote

Title

Procedure Note

Experimental

False

Realm

Authority

hl7

Description

A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act. The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patient's tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care. #### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template: **Required Sections** - [AssessmentandPlanSection](StructureDefinition-AssessmentandPlanSection.html) or both [AssessmentSection](StructureDefinition-AssessmentSection.html) and [PlanofTreatmentSection](StructureDefinition-PlanofTreatmentSection.html) - [ComplicationsSection](StructureDefinition-ComplicationsSection.html) - [ProcedureDescriptionSection](StructureDefinition-ProcedureDescriptionSection.html) - [ProcedureIndicationsSection](StructureDefinition-ProcedureIndicationsSection.html) - [PostprocedureDiagnosisSection](StructureDefinition-PostprocedureDiagnosisSection.html) **Additional Sections** - [AllergiesAndIntolerancesSection](StructureDefinition-AllergiesAndIntolerancesSection.html) - [AnesthesiaSection](StructureDefinition-AnesthesiaSection.html) - [ChiefComplaintSection](StructureDefinition-ChiefComplaintSection.html) - [ChiefComplaintandReasonforVisitSection](StructureDefinition-ChiefComplaintandReasonforVisitSection.html) - [FamilyHistorySection](StructureDefinition-FamilyHistorySection.html) - [PastMedicalHistory](StructureDefinition-PastMedicalHistory.html) - [HistoryofPresentIllnessSection](StructureDefinition-HistoryofPresentIllnessSection.html) - [MedicalGeneralHistorySection](StructureDefinition-MedicalGeneralHistorySection.html) - [MedicationsSection](StructureDefinition-MedicationsSection.html) - [MedicationsAdministeredSection](StructureDefinition-MedicationsAdministeredSection.html) - [PhysicalExamSection](StructureDefinition-PhysicalExamSection.html) - [PlannedProcedureSection](StructureDefinition-PlannedProcedureSection.html) - [ProcedureDispositionSection](StructureDefinition-ProcedureDispositionSection.html) - [ProcedureEstimatedBloodLossSection](StructureDefinition-ProcedureEstimatedBloodLossSection.html) - [ProcedureFindingsSection](StructureDefinition-ProcedureFindingsSection.html) - [ProcedureImplantsSection](StructureDefinition-ProcedureImplantsSection.html) - [ProcedureSpecimensTakenSection](StructureDefinition-ProcedureSpecimensTakenSection.html) - [ProceduresSection](StructureDefinition-ProceduresSection.html) - [ReasonforVisitSection](StructureDefinition-ReasonforVisitSection.html) - [ReviewofSystemsSection](StructureDefinition-ReviewofSystemsSection.html) - [SocialHistorySection](StructureDefinition-SocialHistorySection.html) - [AdvanceDirectivesSection](StructureDefinition-AdvanceDirectivesSection.html)

Type

http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument

Kind

logical

Resources that use this resource

No resources found

Resources that this resource uses

StructureDefinition

http://hl7.org/cda/stds/core/StructureDefinition/Section

Section (CDA Class)

AdvanceDirectivesSection

Advance Directives Section

AllergiesAndIntolerancesSection

Allergies and Intolerances Section

AnesthesiaSection

Anesthesia Section

AssessmentSection

Assessment Section

AssessmentandPlanSection

Assessment and Plan Section

ChiefComplaintSection

Chief Complaint Section

ChiefComplaintandReasonforVisitSection

Chief Complaint and Reason for Visit Section

ComplicationsSection

Complications Section

FamilyHistorySection

Family History Section

HistoryofPresentIllnessSection

History of Present Illness Section

MedicalGeneralHistorySection

Medical (General) History Section

MedicationsAdministeredSection

Medications Administered Section

MedicationsSection

Medications Section

PastMedicalHistory

Past Medical History

PhysicalExamSection

Physical Exam Section

PlannedProcedureSection

Planned Procedure Section

PlanofTreatmentSection

Plan of Treatment Section

PostprocedureDiagnosisSection

Postprocedure Diagnosis Section

ProcedureDescriptionSection

Procedure Description Section

ProcedureDispositionSection

Procedure Disposition Section

ProcedureEstimatedBloodLossSection

Procedure Estimated Blood Loss Section

ProcedureFindingsSection

Procedure Findings Section

ProcedureImplantsSection

Procedure Implants Section

ProcedureIndicationsSection

Procedure Indications Section

ProcedureSpecimensTakenSection

Procedure Specimens Taken Section

ProceduresSection

Procedures Section

ReasonforVisitSection

Reason for Visit Section

ReviewofSystemsSection

Review of Systems Section

SocialHistorySection

Social History Section

USRealmHeader

US Realm Header

Narrative

Note: links and images are rebased to the (stated) source

Generated Narrative: StructureDefinition ProcedureNote

Description & Constraints

ClinicalDocument

1..1

USRealmHeader

XML Namespace: urn:hl7-org:v3
Elements defined in Ancestors:@nullFlavor, @classCode, @moodCode, realmCode, typeId, templateId, id, sdtcCategory, code, title, sdtcStatusCode, effectiveTime, confidentialityCode, languageCode, setId, versionNumber, copyTime, recordTarget, author, dataEnterer, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, relatedDocument, authorization, componentOf, component, realmCode, typeId, templateId, templateId, id, code, title, effectiveTime, languageCode, setId, versionNumber, recordTarget, author, dataEnterer, informant, informant, informant, custodian, informationRecipient, legalAuthenticator, authenticator, participant, inFulfillmentOf, documentationOf, authorization, componentOf
Base for all types and resources
Instance of this type are validated by templateId
Logical Container: ClinicalDocument (CDA Class)
category-28570-0: If category is present, then there shall be a category with LOINC code '28570-0'.
should-componentOf: SHOULD contain componentOf

templateId

2..*

Slices for templateId

Content/Rules for all slices

templateId:procedure-note

1..1

@root

1..1

oid, uuid, ruid

Required Pattern: 2.16.840.1.113883.10.20.22.1.6

@extension

1..1

Required Pattern: 2024-05-01

sdtcCategory

0..*

Used to categorize the document as a Procedure Note. If present, there SHALL be a category of 28570-0 (Procedure note).

code

1..1

The Procedure Note recommends use of a single document type code, 28570-0 "Procedure note", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
Binding: ProcedureNoteDocumentTypeCodes

(required)

Slices for participant

0..*

Participant1

The participant element in the Procedure Note header follows the General Header Constraints for participants.
Slice: Unordered, Open by value:typeCode, value:functionCode.code

participant:participant1

0..*

Participant1

The participant element identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).

@typeCode

1..1

Fixed Value: IND

functionCode

1..1

@code

1..1

Required Pattern: PCP

@codeSystem

1..1

oid, uuid, ruid

Required Pattern: 2.16.840.1.113883.5.88

associatedEntity

@classCode

1..1

Fixed Value: PROV

1..1

1..*

A serviceEvent is required in the Procedure Note to represent the main act, such as a colonoscopy or a cardiac stress study, being documented. It must be equivalent to or further specialize the value inherent in the ClinicalDocument/@code (such as where the ClinicalDocument/@code is simply "Procedure Note" and the procedure is "colonoscopy"), and it shall not conflict with the value inherent in the ClinicalDocument/@code, as such a conflict would create ambiguity. A serviceEvent/effectiveTime element indicates the time the actual event (as opposed to the encounter surrounding the event) took place. serviceEvent/effectiveTime may be represented two different ways in the Procedure Note. For accuracy to the second, the best method is effectiveTime/low together with effectiveTime/high. If a more general time, such as minutes or hours, is acceptable OR if the duration is unknown, an effectiveTime/low with a width element may be used. If the duration is unknown, the appropriate HL7 null value such as "NI" or "NA" must be used for the width element.

serviceEvent

1..1

ServiceEvent

A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.

code

0..1

Binding Description (No ValueSet): (required): The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8511).

Additional Bindings

Purpose

Documentation

Procedure

Preferred

Allowed SNOMED Codes

1198-8511: The value of Clinical Document /documentationOf/serviceEvent/code **SHALL** be from ICD9 CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), HCPCS (codeSystem 2.16.840.1.113883.6.285), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure *DYNAMIC* (CONF:1198-8511).

effectiveTime

1..1

USRealmDateTimeInterval

Base for all types and resources
width-or-high: Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.

low

1..1

IVXB_TS

Low is required

(Choice of one)

1..1

width

0..1

Represents the duration

high

0..1

IVXB_TS

Equals low if only the date is known

Slices for performer

1..*

Performer1

The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
Slice: Unordered, Open by value:typeCode

performer:primary

1..1

Performer1

This performer participant represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have the appropriate privileges in their institutions such as gastroenterologists, interventional radiologists, and family practice physicians. Performers may also be non-physician providers (NPPs) who have other significant roles in the procedure such as a radiology technician, dental assistant, or nurse. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.

@typeCode

1..1

Fixed Value: PPRF

assignedEntity

1..1

AssignedEntity

should-code: SHOULD contain code

code

0..1

Binding: Healthcare Provider Taxonomy

(required)

performer:secondary

0..*

Performer1

@typeCode

1..1

Fixed Value: SPRF

assignedEntity

1..1

AssignedEntity

should-code: SHOULD contain code

code

0..1

Binding: Healthcare Provider Taxonomy

(required)

authorization

0..1

Authorization

Authorization represents consent. Consent, if present, shall be represented by authorization/consent.

1..1

1..1

1..1

1..1

0..1

The encompassing encounter represents the setting of the clinical encounter during which the document act(s) or ServiceEvent(s) occurred. In order to represent providers associated with a specific encounter, they are recorded within the encompassingEncounter as participants. In a CCD, the encompassingEncounter may be used when documenting a specific encounter and its participants. All relevant encounters in a CCD may be listed in the encounters section.

encompassingEncounter

1..1

EncompassingEncounter

should-id: SHOULD contain id

1..*

SG 20230709: EncompassingEncounter.id is required in US Realm Header - this is an illegal constraint - deleted min=0

code

1..1

Slices for encounterParticipant

0..*

EncounterParticipant

Slice: Unordered, Open by value:typeCode