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

Procedure Activity Procedure

[Procedure: templateId 2.16.840.1.113883.10.20.22.4.14]

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 procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy.

  1. SHALL contain exactly one [1..1] templateId ( CONF:7654 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.14"
  2. SHALL contain exactly one [1..1] @classCode="PROC" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7652)
  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:7653)
  4. SHALL contain at least one [1..*] id (CONF:7655)
  5. SHALL contain exactly one [1..1] code (CONF:7656)
  6. SHALL contain exactly one [1..1] statusCode, where the @code SHALL be selected from ValueSet ProcedureActStatusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:7661)
  7. SHOULD contain zero or one [0..1] effectiveTime (CONF:7662)
  8. MAY contain zero or more [0..*] specimen (CONF:7697)

    This specimen is for representing specimens obtained from a procedure.

    1. Such specimens SHALL contain exactly one [1..1] specimenRole (CONF:7704)
    2. Such specimens specimenRole SHOULD contain zero or more [0..*] id (CONF:7716)
    3. Such specimens To indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id. (CONF:7717)
  9. MAY contain zero or more [0..*] participant (CONF:7765, CONF:7752, CONF:15912)
    1. Contains exactly one [1..1] Service Delivery Location (templateId: 2.16.840.1.113883.10.20.22.4.32)
  10. SHOULD contain zero or more [0..*] performer (CONF:7718)
    1. Such performers SHALL contain exactly one [1..1] assignedEntity (CONF:7720)
      1. This assignedEntity SHALL contain at least one [1..*] id (CONF:7722)
      2. This assignedEntity SHALL contain exactly one [1..1] addr (CONF:7731)
      3. This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:7732)
      4. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:7733)
        1. This representedOrganization SHOULD contain zero or more [0..*] id (CONF:7734)
        2. This representedOrganization MAY contain zero or more [0..*] name (CONF:7735)
        3. This representedOrganization SHALL contain exactly one [1..1] telecom (CONF:7737)
        4. This representedOrganization SHALL contain exactly one [1..1] addr (CONF:7736)
  11. MAY contain zero or one [0..1] entryRelationship (CONF:7886, CONF:7887, CONF:15915)
    1. Contains @typeCode="COMP" COMP
    2. Contains exactly one [1..1] Medication Activity (templateId: 2.16.840.1.113883.10.20.22.4.16)
  12. MAY contain zero or one [0..1] entryRelationship (CONF:7775, CONF:7776, CONF:15913)
    1. Contains @typeCode="SUBJ" SUBJ
    2. Contains exactly one [1..1] Instructions (templateId: 2.16.840.1.113883.10.20.22.4.20)
  13. MAY contain zero or more [0..*] entryRelationship (CONF:7779, CONF:7780, CONF:15914)
    1. Contains @typeCode="RSON" RSON
    2. Contains exactly one [1..1] Indication (templateId: 2.16.840.1.113883.10.20.22.4.19)
  14. 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:7668)
  15. MAY contain zero or one [0..1] methodCode (CONF:7670)
  16. SHOULD contain zero or more [0..*] targetSiteCode (CONF:7683), where the @code SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 STATIC 2 (CONF:16082)
  17. MAY contain zero or more [0..*] participant (CONF:7751, CONF:7752, CONF:15911)
    1. Contains exactly one [1..1] Product Instance (templateId: 2.16.840.1.113883.10.20.22.4.37)
  18. MAY contain zero or more [0..*] entryRelationship (CONF:7768)
    1. Such entryRelationships SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8009)
    2. Such entryRelationships SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:7769)
    3. Such entryRelationships SHALL contain exactly one [1..1] encounter (CONF:7770)
      1. This encounter SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:7771)
      2. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:7772)
      3. This encounter SHALL contain exactly one [1..1] id (CONF:7773)
      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:16843)
  19. code in a procedure activity SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12), ICD9 Procedures (codeSystem 2.16.840.1.113883.6.104), ICD10 Procedure Coding System (codeSystem 2.16.840.1.113883.6.4) (CONF:7657)
  20. code SHOULD contain zero or one [0..1] originalText (CONF:7658)
  21. originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:15908)
  22. reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15909)
  23. 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:15910)
  24. methodCode SHALL NOT conflict with the method inherent in Procedure / code (CONF:7890)
  25. entryRelationship with target entry encounter SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8009)
  26. participant with target entry Product Instance SHALL contain exactly one [1..1] @typeCode="DEV" Device (CodeSystem: 2.16.840.1.113883.5.1002 HL7ActRelationshipType) STATIC (CONF:7752)
  27. participant with target entry Service Delivery Location SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: 2.16.840.1.113883.5.1002 HL7ActRelationshipType) STATIC (CONF:7766)
  28. entryRelationship with target entry Instructions SHALL contain exactly one [1..1] @inversionInd="true" (CONF:7777)

Procedure Activity Procedure example

<procedure xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="49616260"/>
  <code code="1213953883"/>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <priorityCode code="756082600"/>
  <methodCode code="719526095"/>
  <targetSiteCode code="525600506"/>
  <specimen>
    <specimenRole/>
  </specimen>
  <performer>
    <assignedEntity>
      <id root="MDHT" extension="939245944"/>
      <addr/>
      <telecom/>
      <representedOrganization/>
    </assignedEntity>
  </performer>
  <entryRelationship typeCode="COMP" inversionInd="true">
    <encounter classCode="ENC" moodCode="EVN">
      <id root="MDHT" extension="1159158159"/>
    </encounter>
  </entryRelationship>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="610557087"/>
      <code code="1052247058"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <priorityCode code="681274142"/>
      <methodCode code="2023910897"/>
      <targetSiteCode code="4177949"/>
    </observation>
  </entryRelationship>
  <entryRelationship>
    <substanceAdministration>
      <id root="MDHT" extension="126392017"/>
      <code code="1656110118"/>
      <effectiveTime value="20130627"/>
      <priorityCode code="628779298"/>
      <consumable>
        <manufacturedProduct/>
      </consumable>
      <performer/>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="728767468"/>
          <code code="64115580"/>
          <effectiveTime value="20130627"/>
          <priorityCode code="1823561627"/>
          <author/>
          <entryRelationship>
            <act/>
          </entryRelationship>
        </supply>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="545717816"/>
          <code code="548755630"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="926589209"/>
          <methodCode code="1393541453"/>
          <targetSiteCode code="1101221103"/>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <procedure/>
          </entryRelationship>
          <entryRelationship>
            <substanceAdministration/>
          </entryRelationship>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <act>
          <id root="MDHT" extension="1207789238"/>
          <code code="930736782"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="998732683"/>
        </act>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="335496608"/>
          <code code="1683373812"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="988769000"/>
          <methodCode code="304821618"/>
          <targetSiteCode code="621724066"/>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="754438495"/>
          <code code="1632256130"/>
          <effectiveTime value="20130627"/>
          <priorityCode code="692603474"/>
          <performer/>
          <entryRelationship>
            <supply/>
          </entryRelationship>
        </supply>
      </entryRelationship>
      <precondition>
        <criterion/>
      </precondition>
    </substanceAdministration>
  </entryRelationship>
  <entryRelationship>
    <act>
      <id root="MDHT" extension="2096313891"/>
      <code code="1585984501"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <priorityCode code="34037693"/>
    </act>
  </entryRelationship>
</procedure>