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 Template  Entry Executed Surgical Procedures

Template 1.3.6.1.4.1.19376.1.5.3.1.4.19 - EntryProcedures
Id 1.3.6.1.4.1.19376.1.5.3.1.4.19
Classification CDA entry level template
Context Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.19
Version valid from 2013‑06‑04 status Active
Open/Closed Open (other than defined elements are allowed)
Description Template CDA entry Procedures
Associated with
Associated with 3 concepts
Id Name as of
epsos-dataelement-1 Surgical Procedure 2013‑05‑31
epsos-dataelement-2 Procedure Id (code) 2013‑05‑31
epsos-dataelement-3 Procedure description 2013‑05‑31
Used in
Used in 1 template
Id Name as of
epsos-template-9 SectionProcedures  Section Procedures 2013‑06‑04
link11 Dependency: 1.3.6.1.4.1.12559.11.10.1.3.1.1.3 epSOS-PS  epSOS-Patient Summary 2012‑05‑03
link11 Dependency: epsos-template-7 SectionHistoryOfPastIllnesses  Section History Of Past Illnesses 2013‑06‑04
Example
Patient had an operation on his urinary system in Feb, 2011
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
  <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>
  <effectiveTime value="201102"/>
</procedure>
Item DT Card Conf Desc Label
hl7:procedure
R Executed Surgical Procedures (EntryProcedures)
treetree @classCode
1 .. 1 F PROC
treetree @moodCode
1 .. 1   @moodCode shall be out of choice:
  • EVN
  • INT
target Target of concept id(s)
epsos-dataelement-1 Surgical Procedure
treetree hl7:templateId
II 1 .. 1 R (EntryProcedures)
treeblank treetree @root
1 .. 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.19
Example
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/>
treetree hl7:id
II 0 .. * R This required element shall contain an identifier for the procedure. More than one procedure identi-fier may be present. (EntryProcedures)
treetree hl7:code
CD 0 .. 1 R Procedure Id Code. This element shall be present and should contain a code describing the type of procedure. R9.2
treeblank treetree @displayName
0 .. 1  
  Procedure description
CONF
The value of @code shall be drawn from value set epSOSProcedures (DYNAMIC)
target Target of concept id(s)
epsos-dataelement-2 Procedure Id (code)
Example
<code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>
treetree hl7:text
ED 0 .. 1 R Description of procedures (EntryProcedures)
Example
<text>Operation on urinary system</text>
treetree hl7:statusCode
CS 0 .. 1 R This 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'. (EntryProcedures)
CONF
The value of @code shall be drawn from value set ActStatus (DYNAMIC)
alert Error: Cannot find value set "ActStatus"
Example
<statusCode code="completed"/>
treetree hl7:effectiveTime
IVL_TS 0 .. 1 R Procedure Date. 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. R9.3
target Target of concept id(s)
epsos-dataelement-3 Procedure description
treetree hl7:priorityCode
CE 0 .. 1 R This element shall be present in INT mood when effectiveTime is not provided, it may be present in 2550 other moods. It indicates the priority of the procedure. (EntryProcedures)
CONF
The value of @code shall be drawn from value set ActPriority (DYNAMIC)
alert Error: Cannot find value set "ActPriority"
treetree hl7:approachSiteCode
CD 0 .. 1 This element may be present to indicate the procedure approach. (EntryProcedures)
CONF
The value of @code shall be drawn from value set ActSite (DYNAMIC)
alert Error: Cannot find value set "ActSite"
Example
<code code="RLAQ" codeSystem="2.16.840.1.113883.5.1052" codeSystemName="ActSite" displayName="right lower abd quadrant"/>
treetree hl7:targetSiteCode
CD 0 .. * This element may be present to indicate the target site of the procedure. (EntryProcedures)
Example
<targetSiteCode code="76552005" codeSystem="2.16.840.1.113883.6.96" displayName="skin structure of shoulder">
  <qualifier>
    <name code="272741003" displayName="Laterality"/>
    <value code="7771000" displayName="Left"/>
  </qualifier>
</targetSiteCode>