Procedure Refused

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 12/8/2019
  • SDWG: 6/27/2019

Templates

  • Procedure Section: 2.16.840.1.113883.10.20.22.2.7.1:2014-06-09
  • Procedure Actitivy Procedure: 2.16.840.1.113883.10.20.22.4.14:2014-06-09
  • Reason: 2.16.840.1.113883.10.20.24.3.88:2014-12-01

Validation location:

TBD

Reference to full CDA sample: N/A

Comments

  • This is an example of a patient refusing a procedure.

Custodian

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

Keywords

  • procedure, negation

Permalink

 

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>Procedure</th>
					<th>Date and Time (Range)</th>
					<th>Comment</th>
					<th>Reason</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Procedure1">
					<td ID="ProcedureDesc1">Laparoscopic appendectomy</td>
					<td>03 Feb 2014 09:22am </td>
					<td ID="Procedure_0_comment">Not Done</td>
					<td ID="Procedure_0_reason">Patient refused</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<!-- Procedures should be used for care that directly changes the patient's physical state.-->
		<!-- negationInd=true indicates the procedure didn't happen -->
		<procedure moodCode="EVN" classCode="PROC" negationInd="true">
			<templateId root="2.16.840.1.113883.10.20.22.4.14" />
			<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
			<id root="bd4ef764-d7f8-4484-8f65-a776e30816d5"/>
			<code code="6025007" displayName="Laparoscopic appendectomy"
				codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
				<originalText>
					<reference value="#ProcedureDesc1"/>
				</originalText>
				<translation codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT" code="44970"
					displayName="Laparoscopic Appendectomy"/>
				<translation codeSystem="2.16.840.1.113883.6.4" codeSystemName="ICD-10-PCS"
					code="0DTJ4ZZ"
					displayName="Resection of Appendix, Percutaneous Endoscopic Approach"/>
				<translation codeSystem="2.16.840.1.113883.6.104" codeSystemName="ICD-9-CM"
					code="47.01" displayName="Laparoscopic appendectomy"/>
			</code>
			<text>
				<reference value="#Procedure1"/>
			</text>
			<!-- statusCode is completed because the procedure is complete, even though NOT done -->
			<!-- Systems may include statuCode in the narrative (section.text) - if they do it's 
				important to make clear procedure was NOT done -->
			<statusCode code="completed"/>
			<!-- Effective times can be either a value or interval. For procedures with start and stop times, an interval would be more appropriate -->
			<effectiveTime value="20140203092205-0500"/>
			<!-- Comment activity --> 
			<entryRelationship typeCode="REFR">
				<act classCode="ACT" moodCode="EVN">
					<templateId root="2.16.840.1.113883.10.20.22.4.64"/>
					<code code="48767-8" displayName="Annotation Comment" codeSystemName="LOINC" codeSystem="2.16.840.1.113883.6.1"/>
					<text>
						<reference value="#Procedure_0_comment"/>
					</text>
				</act>
			</entryRelationship>
			<!-- This is the QRDA template --> 
			<entryRelationship typeCode="REFR">
				<observation classCode="OBS" moodCode="EVN">
					<!-- Reason (V2) -->
					<templateId root="2.16.840.1.113883.10.20.24.3.88" extension="2014-12-01" />
					<id root="5750a5bb-6a01-4b99-9b1c-cda56b1dce0c" />
					<code code="77301-0" codeSystem="2.16.840.1.113883.6.1" displayName="Reason care action performed or not" codeSystemName="LOINC" />
					<statusCode code="completed" />
					<text>
						<reference value="#Procedure_0_reason"/>
					</text>
					<effectiveTime>
						<low value="20140203092205-0500"/>
					</effectiveTime>
					<!-- sdtc:valueset extension is required in many QRDA templates. It's allowed in C-CDA. -->
					<value xsi:type="CD" code="105480006" codeSystem="2.16.840.1.113883.6.96"  codeSystemName="SNOMED CT" displayName="Refusal of treatment by patient" sdtc:valueSet="2.16.840.1.113883.3.526.3.1008" />
				</observation>
			</entryRelationship>
		</procedure>
	</entry>
</section>
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