Back To Index  <<  Back To Templates

active Template  eHDSI Procedure

Id 1.3.6.1.4.1.12559.11.10.1.3.1.3.26 Effective Date 2022‑04‑19 09:15:14
Other versions this id:
Status active Active Version Label
Name eHDSIProcedure Display Name eHDSI Procedure
Description

The procedure entry is used to record procedures that have occured, or which are planned for in the future.

Context Parent nodes of template element with id 1.3.6.1.4.1.12559.11.10.1.3.1.3.26
Classification CDA Entry Level Template
Open/Closed Open (other than defined elements are allowed)
Associated with
Associated with 4 concepts
Id Name Data Set
ehdsi-dataelement-47 draft Body site draft eHDSI Data Set
ehdsi-dataelement-49 draft Procedure description draft eHDSI Data Set
ehdsi-dataelement-48 draft Procedure code draft eHDSI Data Set
ehdsi-dataelement-46 draft Procedure date draft eHDSI Data Set
Used by / Uses
Used by 2 transactions and 9 templates, Uses 1 template
Used by as Name Version
epsos-transactions-23 Transaction draft Return MRO 2013‑11‑02
epsos-transactions-12 Transaction draft Return PS of country A 2012‑05‑02
1.3.6.1.4.1.12559.11.10.1.3.1.2.11 Containment active eHDSI List of Surgeries 2020‑09‑02 14:24:38
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link active eHDSI Patient Summary 2022‑09‑12 13:44:19
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired eHDSI Patient Summary 2020‑09‑02 10:19:44
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Containment active eHDSI Coded Results 2022‑04‑06 14:48:38
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired eHDSI Patient Summary 2020‑04‑14 13:03:47
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired epSOS-Patient Summary 2018‑11‑14 10:53:50
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 link retired epSOS-Patient Summary 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 link retired epSOS-Health Care Encounter Report 2018‑11‑14 09:02:41
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 Containment retired eHDSI Coded Results 2020‑09‑04 10:21:34
Uses as Name Version
1.3.6.1.4.1.12559.11.10.1.3.1.3.14 Containment active eHDSI Internal Reference DYNAMIC
Relationship Version: template 1.3.6.1.4.1.12559.11.10.1.3.1.3.26 eHDSI Procedure (2020‑09‑03 12:58:22)
Adaptation: template 1.3.6.1.4.1.19376.1.5.3.1.4.19 eHDSI Procedure (DYNAMIC)
Example
Example
<procedure classCode="PROC" moodCode="EVN|INT">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.26"/>  <templateId root="2.16.840.1.113883.10.20.1.29"/>  <!-- see text of section -->
  <templateId root="2.16.840.1.113883.10.20.1.25"/>  <!-- see text of section -->
  <id root="1.2.3.999" extension="__example only__"/>  <code code="" codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>  <text>
    <reference value="#xxx"/>  </text>  <statusCode code="completed|active|aborted|cancelled"/>  <effectiveTime>
    <low value=""/>    <high value=""/>  </effectiveTime>  <priorityCode code=""/>  <approachSiteCode code="" displayName="" codeSystem="" codeSystemName=""/>  <targetSiteCode code="" displayName="" codeSystem="" codeSystemName=""/>  <author/>  <informant/>  <entryRelationship typeCode="COMP" inversionInd="true">
    <act classCode="ACT" moodCode="">
      <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.14"/>      <id root="" extension=""/>    </act>  </entryRelationship>  <entryRelationship typeCode="RSON">
    <act classCode="ACT" moodCode="EVN">
      <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.14"/>      <id root="" extension=""/>    </act>  </entryRelationship></procedure>
Example
Patient had an operation on his urinary system in Feb, 2011
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.26"/>  <id root="1.2.3.999" extension="__example only__"/>  <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>  <statusCode code="completed"/>  <effectiveTime value="201102"/></procedure>
Example
No information available
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.26"/>  <id root="2.999.1" extension="__example only__"/>  <code code="no-procedure-info" displayName="No information about past history of procedures" codeSystem="2.16.840.1.113883.5.1150.1" codeSystemName="IPS Absent and Unknown Data"/>  <text>
    <reference value="#Procedures_Unknown"/>  </text>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA" xsi:type="IVL_TS"/></procedure>
Example
Known absence
<procedure classCode="PROC" moodCode="EVN">
  <templateId root="1.3.6.1.4.1.12559.11.10.1.3.1.3.26"/>  <id root="2.999.3.1" extension="__example only__"/>  <code code="no-known-procedures" displayName="No known procedures" codeSystem="2.16.840.1.113883.5.1150.1" codeSystemName="IPS Absent and Unknown Data"/>  <text>
    <reference value="#Procedures_None"/>  </text>  <statusCode code="completed"/>  <effectiveTime nullFlavor="NA" xsi:type="IVL_TS"/></procedure>
Item DT Card Conf Description Label
hl7:procedure
 		R

The templateId indicates that this <procedure> entry conforms to the constraints of this content module. NOTE: When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29, and when in intent mood, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25.

(eHDdotsure)
@classCode
 		cs 1 … 1 F PROC
@moodCode
 		cs 1 … 1 R
  CONF
@moodCode shall be "EVN"
or
@moodCode shall be "INT"
hl7:templateId
 		II.EPSOS 1 … 1 M eHDSI Procedure (eHDdotsure)
@root
 		uid 1 … 1 F 1.3.6.1.4.1.12559.11.10.1.3.1.3.26
hl7:templateId
 		II.EPSOS 0 … 1 R IHE Procedure Entry (IHE PCC) (eHDdotsure)
@root
 		uid 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.4.19
Choice  … 1 Elements to choose from:
  • hl7:templateId[@root = '2.16.840.1.113883.10.20.1.29']
  • hl7:templateId[@root = '2.16.840.1.113883.10.20.1.25']
hl7:templateId
 		II.EPSOS 0 … 1 C When the procedure is in event mood (moodCode='EVN'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.29 (eHDdotsure)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.1.29
hl7:templateId
 		II.EPSOS 0 … 1 C When the procedure is in intent mood (moodCode='INT'), this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25. (eHDdotsure)
@root
 		uid 1 … 1 F 2.16.840.1.113883.10.20.1.25
hl7:id
 		II.EPSOS 1 … * R This required element shall contain an identifier for the procedure. More than one procedure identi-fier may be present. (eHDdotsure)
hl7:code
 		CE.EPSOS 1 … 1 R Procedure Id Code. This element shall be present and should contain a code describing the type of procedure.

One of the concepts from the Value Set eHDSIAbsentOrUnknownProcedure shall be used in the <code> element to record that a patient didn't undergo any surgeries, or that surgeries are not known.
 R9.2
 
target
ehdsi-dataelement-48 draft Procedure code draft eHDSI Data Set
@displayName
 		0 … 1   Procedure description R9.1
@nullFlavor
 		cs 0 … 1  
  CONF
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.10 eHDSIProcedure (DYNAMIC)
or
The value of @code shall be drawn from value set 1.3.6.1.4.1.12559.11.10.1.3.1.42.51 eHDSIAbsentOrUnknownProcedure (DYNAMIC)
  Example <code code="392048005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Operation on urinary system"/>
hl7:text
 		ED 1 … 1 R Description of procedures (eHDdotsure)
 
target
ehdsi-dataelement-49 draft Procedure description draft eHDSI Data Set
hl7:reference
 		TEL 1 … 1 M (eHDdotsure)
@value
 		1 … 1 R Reference pointing to the narrative, typically #{label}-{generated-id}, e.g. #xxx-1
hl7:statusCode
 		CS 1 … 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'. (eHDdotsure)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.1937.777.11.11.3 ActStatusActiveAbortedCancelledCompleted (DYNAMIC)
hl7:effectiveTime
 		IVL_TS 1 … 1 R IHE-PCC: 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.
epSOS: Procedure date is required. 		R9.3
 
target
ehdsi-dataelement-46 draft Procedure date draft eHDSI Data Set
hl7:priorityCode
 		CE.EPSOS 0 … 1 R This element shall be present when the moodCode is 'INT' and the effectiveTime is not provided. It may be present for other moods. It indicates the priority of the procedure. (eHDdotsure)
  CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMIC)
hl7:approachSiteCode
 		CD.EPSOS 0 … 1 R This element may be present to indicate the procedure approach. (eHDdotsure)
@codeSystem
 		CONF 0 … 1 F 2.16.840.1.113883.5.1052 (ActSite)
  Example <code code="RLAQ" codeSystem="2.16.840.1.113883.5.1052" codeSystemName="ActSite" displayName="right lower abd quadrant"/>
hl7:targetSiteCode
 		CD.EPSOS 0 … * R This element may be present to indicate the target site of the procedure. (eHDdotsure)
 
target
ehdsi-dataelement-47 draft Body site draft eHDSI Data Set
  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>
hl7:entryRelationship
 		0 … * R

This element may be present to point the encounter in which the procedure was performed, and shall contain an internal reference to the encounter.

A <procedure> act may indicate one or more reasons for the procedure. These reasons identify the concern that was the reason for the procedure via an Internal Reference to the concern. The extension and root of each observation present must match the identifier of a concern entry contained elsewhere within the CDA document.


Contains 1.3.6.1.4.1.12559.11.10.1.3.1.3.14 eHDSI Internal Reference (DYNAMIC) 		(eHDdotsure)
@inversionInd
 		bl 0 … 1