Procedures Section Procedure Entry - Colonoscopy

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 3/19/2020
  • SDWG: 3/26/2020

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.7.1:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.14:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.119

Reference to full CDA sample:

  • Empty CCD

Validation location

Comments

  • This example illustrates a Colonoscopy procedure which with biopsy. Even if not biopsy, a colonscopy is recommended to be in a Procedure Activity Procedure.

Custodian

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

Keywords

  • procedure

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>Description</th>
					<th>Date and Time (Range)</th>
					<th>Status</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Procedure1">
					<td ID="ProcedureDesc1">Colonoscopy, flexible; with biopsy, single or multiple</td>
					<td>(03 May 2019 09:22am- 03 May 2019 11:15am)</td>
					<td>Completed</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<!-- Procedures should be used for care that directly changes the patient's physical state. -->
                <!-- Colonoscopy with/without Biopsy is appropriate here -->
		<!-- The Procedures section records all completed Procedures -->
		<!-- Biopsies/test/results from the Procedure are expected in the results section -->
		<procedure moodCode="EVN" classCode="PROC">
			<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="56a76ee2-c5a9-4c69-be93-0461bd98691c"/>
			<code code="25732003" displayName="Fiberoptic colonoscopy with biopsy"
				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="45380"
					displayName="Colonoscopy, flexible; with biopsy, single or multiple"/>
			</code>
			<text>
				<reference value="#Procedure1"/>
			</text>
			<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 xsi:type="IVL_TS">
				<low value="20190503092205-0700"/>
				<high value="20190503111514-0700"/>
			</effectiveTime>
		</procedure>
	</entry>
</section>

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