Package | hl7.fhir.us.ccda |
Type | StructureDefinition |
Id | Id |
FHIR Version | R4 |
Source | http://hl7.org/fhir/us/ccda/https://build.fhir.org/ig/HL7/ccda-on-fhir/StructureDefinition-Procedure-Note.html |
Url | http://hl7.org/fhir/us/ccda/StructureDefinition/Procedure-Note |
Version | 2.0.0-ballot |
Status | active |
Date | 2024-12-12T19:41:54+00:00 |
Name | ProcedureNote |
Title | Procedure Note |
Experimental | False |
Realm | us |
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 patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care. |
Type | Composition |
Kind | resource |
CapabilityStatement | |
CcdaOnFhirClient ![]() | CCDA on FHIR Client |
CcdaOnFhirServer ![]() | CCDA on FHIR Server |
StructureDefinition | |
US-Realm-Header ![]() | US Realm Header |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance ![]() | US Core AllergyIntolerance Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter ![]() | US Core Encounter Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal ![]() | US Core Goal Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication ![]() | US Core Medication Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest ![]() | US Core MedicationRequest Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure ![]() | US Core Procedure Profile |
http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus ![]() | US Core Smoking Status Observation Profile |
http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1 ![]() | ProcedureNoteDocumentTypeCodes |
Note: links and images are rebased to the (stated) source
Generated Narrative: StructureDefinition Procedure-Note
version: 9; Last updated: 2020-08-19 06:54:38+0000;
Information Source: #b9WEhafsbLr7h0uf
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
![]() ![]() | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |
![]() ![]() ![]() | S | 1..1 | CodeableConcept | Procedure Note Binding: ProcedureNoteDocumentTypeCodes (required) |
![]() ![]() ![]() | S | 1..* | BackboneElement | serviceEvent |
![]() ![]() ![]() ![]() | 1..1 | Period | period | |
![]() ![]() ![]() ![]() ![]() | 1..1 | dateTime | start | |
![]() ![]() ![]() ![]() ![]() | 1..1 | dateTime | end | |
![]() ![]() ![]() | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Complications Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Complications Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 55109-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Procedure Description Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Procedure description Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 29554-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Procedure Indications Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Procedure indications Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59768-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 1..1 | BackboneElement | Postprocedure Diagnosis Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Postprocedure diagnosis Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59769-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Allergies and Intolerances Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Allergies and/or adverse reactions Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 48765-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core AllergyIntolerance Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Assessment Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Assessments Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51848-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Assessment and plan Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 51847-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile | Observation | Communication) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Anesthesia Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Anesthesia Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 59774-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 46239-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Chief Complaint Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10154-3 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Family History Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10157-6 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(FamilyMemberHistory) | This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Past Medical History Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11348-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | text |
![]() ![]() ![]() ![]() ![]() | 0..* | Reference(Resource) | entry Slice: Unordered, Open by profile:resolve() | |
![]() ![]() ![]() ![]() ![]() ![]() | S | 0..* | Reference(US Core Condition Profile) | A reference to data that supports this section |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | History of Present Illness Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | code Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10164-2 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Medical (General) History Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | CodeableConcept | Medical (general) history Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() ![]() | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 11329-0 | |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | Narrative | This section contains only human readable content |
![]() ![]() ![]() ![]() | S | 0..1 | BackboneElement | Medications Section |
![]() ![]() ![]() ![]() ![]() | S | 1..1 | string | title |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||
![]() ![]() ![]() ![]() ![]() ![]() ![]() | 1..1 |