Procedures Section Act Entry

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Example metadata last updated 2017-09-11 05:11:32.543000 UTC

Approval Status: Approved

  • Approval Status: Approved
  • Example Task Force: 5/22/2014
  • SDWG: 5/29/2014
  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

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Comments:

  • This example illustrates an act within a procedure section.

Custodian: John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Full sample: Problems in empty CCD

Example: download example view on GitHub

<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>Status</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Procedure3">
					<td ID="ProcedureDesc3">Individual Counseling For Medical Nutrition </td>
					<td>29 Mar 2014 10:45am</td>
					<td>Completed</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<!-- Act should be used for care of the patient that cannot be classified as a procedure or observation (e.g. wound dressing change, counseling) -->
		<act classCode="ACT" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.12" extension="2014-06-09"/>
			<id root="9c0f070c-2e9e-4be1-a5b5-ff6d0f68123c"/>
			<code code="61310001" codeSystem="2.16.840.1.113883.6.96" displayName="Nutrition education" codeSystemName="SNOMED-CT">
				<originalText>
					<reference value="#ProcedureDesc3"/>
				</originalText>
				<translation code="97802" codeSystem="2.16.840.1.113883.6.12" displayName="Medical nutrition therapy; initial" codeSystemName="CPT" />
				<translation code="S9470" codeSystem="2.16.840.1.113883.6.13" displayName="Nutritional counseling, diet" codeSystemName="HCPCS"/>
				<!-- For some activities, ICD-9 and ICD-10 procedure codes may not apply (e.g. nutritional counseling). ICD-9 and ICD-10 diagnosis codes translate and shown below-->
				<translation code="V65.3" codeSystem="2.16.840.1.113883.6.103" displayName="Dietary surveillance and counseling" codeSystemName="ICD-9 Diagnosis"/>
				<translation code="Z71.3" codeSystem="2.16.840.1.113883.6.90" displayName="Dietary counseling and surveillance" codeSystemName="ICD-10 Diagnosis"/>
			</code>
			<text>
				<reference value="#Procedure3" />
			</text>
			<statusCode code="completed"/>
			<effectiveTime value="20140329104513+0500"/>
		</act>
	</entry>
</section>
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