Note directly attached to a Procedure

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 6/14/2018
  • SDWG: 7/12/2018

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.7.1
  • 2.16.840.1.113883.10.20.22.2.7.1:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.14
  • 2.16.840.1.113883.10.20.22.4.202:2016-11-01

Reference to full CDA sample:

  • Validated in an empty CCD

Validation location

Comments

  • This is an example of how to associate a Procedure Note with a Procedure in the Procedure section.

Custodian

  • Brett Marquard, brett@waveoneassociates.com (GitHub: brettmarquard)

Keywords

  • Note, Note Activity, Notes, Procedure

 

Example: download example view on GitHub

<?xml version="1.0" encoding="UTF-8"?>
<section>
    <!-- Note directly attached to the associated act -->
    <!-- C-CDA 2.1 Procedures Section -->
    <templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
    <code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
        displayName="HISTORY OF PROCEDURES"/>
    <title>Procedures</title>
    <text>
        <table>
            <thead>
                <tr>
                    <th>Description</th>
                    <th>Date and Time (Range)</th>
                    <th>Notes</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="Procedure1">
                    <td ID="ProcedureDesc1">Laparoscopic appendectomy</td>
                    <td>(03 Feb 2014 09:22am - 03 Feb 2014 11:15am)</td>
                    <td ID="ProcedureNote1">
                        <paragraph>Dr. Physician - 03 Feb 2014</paragraph>
                        <paragraph>Patient repositioned with arms extended on arm
                            boards...</paragraph>

                    </td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry typeCode="DRIV">
        <!-- Procedures should be used for care that directly changes the patient's physical state.-->
        <procedure moodCode="EVN" classCode="PROC">
            <templateId root="2.16.840.1.113883.10.20.22.4.14"/>
            <id root="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
            <code code="6025007" displayName="Laparoscopic appendectomy"
                codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
                <originalText>
                    <reference value="#ProcedureDesc1"/>
                </originalText>
            </code>
            <text>
                <reference value="#Procedure1"/>
            </text>
            <statusCode code="completed"/>
            <effectiveTime>
                <low value="20140203092205-0700"/>
                <high value="20140203111514-0700"/>
            </effectiveTime>
            <!-- Note Activity entry -->
            <entryRelationship typeCode="COMP">
                <act classCode="ACT" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.202" extension="2016-11-01"/>
                    <code code="34109-9" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
                        displayName="Note">
                        <translation code="28570-0" codeSystem="2.16.840.1.113883.6.1"
                            codeSystemName="LOINC" displayName="Procedure note"/>
                    </code>
                    <text>
                        <reference value="#ProcedureNote1"/>
                    </text>
                    <statusCode code="completed"/>
                    <!-- Clinically-relevant time of the note -->
                    <effectiveTime value="20140203"/>
                    <!-- Author Participation -->
                    <author>
                        <templateId root="2.16.840.1.113883.10.20.22.4.119"/>
                        <!-- Time note was actually written -->
                        <time value="20140204083215-0500"/>
                        <assignedAuthor>
                            <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
                            <name>Dr. Physician</name>
                        </assignedAuthor>
                    </author>
                    <!-- Reference to encounter -->
                    <entryRelationship typeCode="COMP" inversionInd="true">
                        <encounter>
                            <!-- Encounter ID matches an encounter in the Encounters Section -->
                            <id root="1.2.3.4"/>
                        </encounter>
                    </entryRelationship>
                </act>
            </entryRelationship>
        </procedure>
    </entry>
</section>
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