Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Procedure Activity Act

[Act: templateId 2.16.840.1.113883.10.20.22.4.12]

The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g. splenectomy).
This clinical statement represents any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures.

  1. SHALL contain exactly one [1..1] templateId ( CONF:10519 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.12"
  2. SHALL contain exactly one [1..1] @classCode="ACT" Act (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:8289)
  3. SHALL contain exactly one [1..1] @moodCode, where the @code SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:8290)
  4. SHALL contain at least one [1..*] id (CONF:8292)
  5. SHALL contain exactly one [1..1] code (CONF:8293)
  6. SHALL contain zero or one [0..1] statusCode, where the @code SHALL be selected from ValueSet ProcedureActStatusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:8298)
  7. SHOULD contain zero or one [0..1] effectiveTime (CONF:8299)
  8. MAY contain zero or one [0..1] priorityCode, where the @code SHALL be selected from ValueSet ActPriority 2.16.840.1.113883.1.11.16866 STATIC (CONF:8300)
  9. SHOULD contain zero or more [0..*] performer (CONF:8301)
    1. Such performers SHALL contain exactly one [1..1] assignedEntity (CONF:7720)
    2. Such performers assignedEntity SHALL contain at least one [1..*] id (CONF:7722)
    3. Such performers assignedEntity SHALL contain exactly one [1..1] addr (CONF:7731)
    4. Such performers assignedEntity SHALL contain exactly one [1..1] telecom (CONF:7732)
    5. Such performers assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:7733)
    6. Such performers representedOrganization, if present, SHOULD contain zero or more [0..*] id (CONF:7734)
    7. Such performers representedOrganization, if present, MAY contain zero or more [0..*] name (CONF:7735)
    8. Such performers representedOrganization, if present, SHALL contain exactly one [1..1] addr (CONF:7736)
    9. Such performers representedOrganization, if present, SHALL contain exactly one [1..1] telecom (CONF:7737)
  10. MAY contain zero or more [0..*] participant (CONF:8311, CONF:8312, CONF:15599)
    1. Contains exactly one [1..1] Service Delivery Location (templateId: 2.16.840.1.113883.10.20.22.4.32)
  11. MAY contain zero or one [0..1] entryRelationship (CONF:8325)
    1. Contains @typeCode="SUBJ" SUBJ
    2. Contains exactly one [1..1] Instructions (templateId: 2.16.840.1.113883.10.20.22.4.20)
  12. MAY contain zero or more [0..*] entryRelationship (CONF:8328)
    1. Contains @typeCode="RSON" RSON
    2. Contains exactly one [1..1] Indication (templateId: 2.16.840.1.113883.10.20.22.4.19)
  13. MAY contain zero or one [0..1] entryRelationship (CONF:8329)
    1. Contains @typeCode="COMP" COMP
    2. Contains exactly one [1..1] Medication Activity (templateId: 2.16.840.1.113883.10.20.22.4.16)
  14. MAY contain zero or more [0..*] entryRelationship (CONF:8314)
    1. Such entryRelationships SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8316)
    2. Such entryRelationships SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:8315)
    3. Such entryRelationships SHALL contain exactly one [1..1] encounter (CONF:8317)
      1. This encounter SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:8318)
      2. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:8319)
      3. This encounter SHALL contain exactly one [1..1] id (CONF:8320)
      4. This encounter MAY satisfy: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter. (CONF:16849)
  15. code in a procedure activity observation SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) (CONF:8294)
  16. code SHOULD contain zero or one [0..1] originalText (CONF:15596)
  17. originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:15596)
  18. reference, if present, MAY contain zero or one [0..1] @value (CONF:15597)
  19. reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:15598)
  20. entryRelationship with target class encounter SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8316)
  21. participant with target class Service Delivery Location SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: 2.16.840.1.113883.5.1002 HL7ActRelationshipType) STATIC (CONF:8312)
  22. entryRelationship with target class Instructions SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8324)

Procedure Activity Act example

<act xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1441818695"/>
  <code code="2119781573"/>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <priorityCode code="1674618885"/>
  <performer>
    <assignedEntity/>
  </performer>
  <entryRelationship typeCode="COMP" inversionInd="true">
    <encounter classCode="ENC" moodCode="EVN">
      <id root="MDHT" extension="1623442452"/>
    </encounter>
  </entryRelationship>
  <entryRelationship>
    <act>
      <id root="MDHT" extension="586385467"/>
      <code code="260183458"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <priorityCode code="1477088144"/>
    </act>
  </entryRelationship>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="2122083157"/>
      <code code="1606672347"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <priorityCode code="1844675833"/>
    </observation>
  </entryRelationship>
  <entryRelationship>
    <substanceAdministration>
      <id root="MDHT" extension="65736409"/>
      <code code="1930963877"/>
      <effectiveTime value="20130627"/>
      <priorityCode code="292544021"/>
      <consumable>
        <manufacturedProduct/>
      </consumable>
      <performer/>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="1073015608"/>
          <code code="1643508002"/>
          <effectiveTime value="20130627"/>
          <priorityCode code="99148220"/>
          <author/>
          <entryRelationship>
            <act/>
          </entryRelationship>
        </supply>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="1962565455"/>
          <code code="462766308"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="299903542"/>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <procedure/>
          </entryRelationship>
          <entryRelationship>
            <substanceAdministration/>
          </entryRelationship>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <act>
          <id root="MDHT" extension="1343931384"/>
          <code code="586999585"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="1727457900"/>
        </act>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="1112339905"/>
          <code code="447982481"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="1116665822"/>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="1371201686"/>
          <code code="398742019"/>
          <effectiveTime value="20130627"/>
          <priorityCode code="1754726043"/>
          <performer/>
          <entryRelationship>
            <supply/>
          </entryRelationship>
        </supply>
      </entryRelationship>
      <precondition>
        <criterion/>
      </precondition>
    </substanceAdministration>
  </entryRelationship>
</act>