Procedures Section Observation Entry

return to Main screen return to result list

Example metadata last updated 2017-12-11 19:21:12.333000 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

SITE C-CDA Validator

Comments:

  • This example illustrates how an observation within a procedure section.

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

Full sample: Procedure 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="Procedure2">
					<td ID="ProcedureDesc2">Electrocardiogram (12-Lead)</td>
					<td>29 Mar 2014 09:15am</td>
					<td>Completed</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<!-- Observations should be used for care that result in information about the patient (e.g. a diagnostic test & result) but do not alter physical state-->
		<observation classCode="OBS" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.13" extension="2014-06-09"/>
			<id root="c03e5445-af1b-4911-a419-e2782f21448c"/>
			<code code="268400002" codeSystem="2.16.840.1.113883.6.96" displayName="12 lead ECG" codeSystemName="SNOMED-CT">
				<originalText>
					<reference value="#ProcedureDesc2"/>
				</originalText>
				<translation code="93000" codeSystem="2.16.840.1.113883.6.12" displayName="Electrocardiogram, complete" codeSystemName="CPT" />
				<translation code="G8704" codeSystem="2.16.840.1.113883.6.13" displayName="12-Lead Electrocardiogram (Ecg) Performed" codeSystemName="HCPCS"/>
				<translation code="89.52" codeSystem="2.16.840.1.113883.6.104" displayName="Electrocardiogram" codeSystemName="ICD-9 Procedure"/>
				<translation code="4A02X4Z" codeSystem="2.16.840.1.113883.6.4" displayName="Measurement of Cardiac Electrical Activity, External Approach" codeSystemName="ICD-10 Procedure"/>
			</code>
			<text>
				<reference value="#Procedure2" />
			</text>
			<statusCode code="completed"/>
			<effectiveTime value="20140329091522+0500" />
			<!-- When choosing an observation, value records relevant findings-->
			<value xsi:type="CD" code="251135002" codeSystem="2.16.840.1.113883.6.96" displayName="Borderline normal ECG" codeSystemName="SNOMED-CT" />
		</observation>
	</entry>
</section>
  1. C-CDA Example Search Help

    C-CDA Example Search Results
    This screen displays the results of executing the example search criteria against the existing examples recorded in the example database.

  2. Search Criteria Panel

    This panel allow you to further refine your queries and narrow the results

  3. Text Search Words

    Use this field to enter words related to your search. These words can appear in the title, the comments or as part of a special list of keywords associated with the example. The search words should be entered with spaces separating the items.

  4. Filter by example status

    By selecting the various statuses, the search results can be limited to only the example that are set to the selected status(es). By removing all status selections, the filtering is removed and examples from all statuses will be returned (based on any other filtering).

  5. Select only ONC Certified examples

    These are samples referenced in a government rule or certification companion guide.

  6. Execute the search based on the criteria entered (or retrieve all examples if no criteria specified).

  7. The number of results that match the query parameters can be found here.

  8. Use this link to jump back to the initial page of the application (that lists the sections).

  9. This columns list the names of the examples that match the criteria (and the comment for each example).

  10. This columns lists the area in the C-CDA specification (the specification is broken into distinct topics for the various exchangeable documents, the common header, and the sections that occur within the exchangeable documents) that the example demonstrates.

  11. This columns lists the state of the example in the example verification and approval process.

  12. You can select to download the examples directly or navigate to page with the full detailed description of the example.

  13. Tour Complete

    Return to the C-CDA Example Search Results page.