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# Template eHDSI Procedure

Id | 1.3.6.1.4.1.19376.1.5.3.1.4.19 | Effective Date | 2020‑04‑16 13:27:07 Other versions this id: eHDSIProcedure as of 2024‑04‑17 14:46:30 eHDSIProcedure as of 2024‑01‑26 13:56:33 eHDSIProcedure as of 2022‑04‑19 09:15:14 eHDSIProcedure as of 2022‑04‑19 08:42:37 eHDSIProcedure as of 2020‑09‑03 12:58:22 EntryProcedure as of 2019‑04‑09 08:30:24 EntryProcedure as of 2013‑12‑20
Status | Retired | 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. In case no procedures are expected to be recorded, a single “NA” nullFlavored procedure entry shall be included in this section.
Context | Parent nodes of template element with id 1.3.6.1.4.1.19376.1.5.3.1.4.19
Classification | CDA Entry Level Template
Open/Closed | Open (other than defined elements are allowed)
Associated with |
Associated with 3 concepts
Id | Name | Dataset
--- | --- | ---
epsos-dataelement-2 | Procedure Id (code) | epSOS Data Set
epsos-dataelement-3 | Procedure description | epSOS Data Set
epsos-dataelement-4 | Procedure Date | epSOS Data Set
Used by / Uses |
Used by 2 transactions and 9 templates, Uses 1 template
Used by | as | Name | Version
--- | --- | --- | ---
epsos-transactions-23 | Transaction | Return MRO | 2013‑11‑02
epsos-transactions-12 | Transaction | Return PS of country A | 2012‑05‑02
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 | Containment | eHDSI Coded Results | 2020‑04‑16 12:13:16
1.3.6.1.4.1.12559.11.10.1.3.1.2.5 | Containment | Section Coded Results | 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.12 | Containment | eHDSI List of Surgeries | 2020‑04‑16 12:10:44
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 |  | eHDSI Patient Summary | 2020‑04‑14 13:03:47
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 |  | epSOS-Patient Summary | 2018‑11‑14 10:53:50
1.3.6.1.4.1.12559.11.10.1.3.1.1.3 |  | epSOS-Patient Summary | 2013‑12‑20
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 |  | epSOS-Health Care Encounter Report | 2018‑11‑14 09:02:41
1.3.6.1.4.1.12559.11.10.1.3.1.1.4 |  | epSOS-Health Care Encounter Report | 2013‑12‑20
1.3.6.1.4.1.19376.1.5.3.1.3.12 | Containment | Section Coded List of Surgeries | 2013‑12‑20
Uses | as | Name | Version
1.3.6.1.4.1.19376.1.5.3.1.4.4.1 | Containment | eHDSI Internal Reference | DYNAMIC
Relationship | Version: template 1.3.6.1.4.1.19376.1.5.3.1.4.19 Procedure (2013‑12‑20)
Example |
Example
<procedure classCode="PROC" moodCode="EVN|INT"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <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="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/> <id root="" extension=""/> </act> </entryRelationship> <entryRelationship typeCode="RSON"> <act classCode="ACT" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.4.1"/> <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="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <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="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <id extension="8607" root="2.4.5.0.2545055583.3.0.14"/> <code code="no-procedure-info" codeSystem="2.16.840.1.113883.5.1150.1" codeSystemName="IPS Absent and Unknown Data" type="CD"/> <text> <reference value="#Procedures_Unknown"/> </text> <statusCode code="completed"/> <effectiveTime nullFlavor="NA" type="IVL_TS"/></procedure>
Example |
Known absence
<procedure classCode="PROC" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.19"/> <id root="1.2.3.999" extension="__example only__"/> <code code="no-known-procedures" codeSystem="2.16.840.1.113883.5.1150.1" codeSystemName="IPS Absent and Unknown Data" type="CD"/> <text> <reference value="#Procedures_None"/> </text> <statusCode code="completed"/> <effectiveTime nullFlavor="NA" 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. |
@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 |  |
@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 |
@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, this entry conforms to the CCD template 2.16.840.1.113883.10.20.1.25. |
@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. |
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
epsos-dataelement-2 | Procedure Id (code) | epSOS 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 |
epsos-dataelement-3 | Procedure description | epSOS Data Set
hl7:reference | TEL | 1 … 1 | M |  |
@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'. |
| 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
epsos-dataelement-4 | Procedure Date | epSOS Data Set
hl7:priorityCode | CE.EPSOS | 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. |
| 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. |
@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. |
| 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 1.3.6.1.4.1.19376.1.5.3.1.4.4.1 eHDSI Internal Reference (DYNAMIC) |
@inversionInd | bl | 0 … 1 |  |