Implant Without Procedure

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 5/19/2016
  • SDWG: 6/3/2016
  • SDWG C-CDA R2.1 Upgrade: 2/2/2017

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.23
  • 2.16.840.1.113883.10.20.22.2.23:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.14
  • 2.16.840.1.113883.10.20.22.4.14:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.37

Reference to full CDA sample:

  • Empty CCD

Validation location

Comments

  • This is an example of how an author can record an implant when the procedure is unknown.

Custodian

  • Benjamin Flessner (GitHub: benjaminflessner)

Keywords

  • unknown procedure, UDI, implant

Permalink

Links

 

Example: download example view on GitHub 

<component>
    <section>
        <templateId root="2.16.840.1.113883.10.20.22.2.23" extension="2014-06-09"/>
        <templateId root="2.16.840.1.113883.10.20.22.2.23"/>
        <code code="46264-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medical Equipment"/>
        <title>Implants</title>
        <text>
            <table>
                <thead>
                    <tr>
                        <th>Implanted</th>
                        <th>Area</th>
                        <th>Manufacturer</th>
                        <th>Device Identifier</th>
                        <th>Details</th>
                        <th>Model</th>
                        <th>Serial</th>
                        <th>Lot</th>
                    </tr>
                </thead>
                <tbody>
                    <tr>
                        <td ID="implant1">Patellofemoral Component</td>
                        <td>Left: Knee</td>
                        <td>MCK</td>
                        <td>00848486000400</td>
                        <td>Implanted: Qty: 1 on 04/13/2016 by Fleming, Barry</td>
                        <td/>
                        <td>123777</td>
                        <td>ABC634</td>
                    </tr>
                    <tr>
                        <td ID="implant2">Inlay Tibial Component</td>
                        <td>Left: Knee</td>
                        <td>MCK</td>
                        <td>00848486001032</td>
                        <td>Implanted: Qty: 1 on 04/13/2016 by Fleming, Barry</td>
                        <td>MCK7712</td>
                        <td/>
                        <td>ABC124</td>
                    </tr>
                    <tr>
                        <td ID="implant3">Patella Component</td>
                        <td ID="implant3site">Left: Knee</td>
                        <td>MCK</td>
                        <td>00848486000349</td>
                        <td>Implanted: Qty: 1 on 04/13/2016 by Fleming, Barry</td>
                        <td>MCK912</td>
                        <td/>
                        <td>ABC721</td>
                    </tr>
                </tbody>
            </table>
        </text>
        <entry>
            <procedure classCode="PROC" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
                <templateId root="2.16.840.1.113883.10.20.22.4.14"/>
                <id extension="2744" root="1.2.840.114350.1.13.5552.1.7.2.737780"/>
                <code nullFlavor="UNK"/>
                <!-- Procedure is completed, even though the implant is still active -->
                <statusCode code="completed"/>
                <effectiveTime>
                    <!-- Placed Date -->
                    <low value="20160413"/>
                </effectiveTime>
                <!-- Example with qualifier to explicitly convey laterality
             See example #2 for an alternative which does not use qualifier 
             See example #3 for an alternative which does not include any code at all, but still conveys the original site text -->
                <targetSiteCode code="72696002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Knee region structure">
                    <qualifier>
                        <name code="272741003" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="laterality" />
                        <value code="7771000" codeSystem="2.16.840.1.113883.9.96" codeSystemName="SNOMED CT" displayName="left" />
                    </qualifier>
                </targetSiteCode>
                <participant typeCode="DEV">
                    <participantRole classCode="MANU">
                        <templateId root="2.16.840.1.113883.10.20.22.4.37"/>
                        <id assigningAuthorityName="FDA" extension="(01)00848486000400(11)160330(10)ABC634(21)123777" root="2.16.840.1.113883.3.3719"/>
                        <playingDevice>
                            <code nullFlavor="UNK">
                                <originalText>
                                    <reference value="#implant1"/>
                                </originalText>
                            </code>
                        </playingDevice>
                        <!-- From Product Instance template:
                 The scopingEntity/id should correspond to FDA or the appropriate issuing agency. -->
                        <scopingEntity>
                            <id root="2.16.840.1.113883.3.3719"/>
                        </scopingEntity>
                    </participantRole>
                </participant>
            </procedure>
        </entry>
        <entry>
            <procedure classCode="PROC" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
                <templateId root="2.16.840.1.113883.10.20.22.4.14"/>
                <id extension="2745" root="1.2.840.114350.1.13.5552.1.7.2.737780"/>
                <code nullFlavor="UNK"/>
                <statusCode code="completed"/>
                <effectiveTime>
                    <low value="20160413"/>
                </effectiveTime>
                <!-- Example without qualifier -->
                <targetSiteCode code="82169009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Structure of left knee region"/>
                <participant typeCode="DEV">
                    <participantRole classCode="MANU">
                        <templateId root="2.16.840.1.113883.10.20.22.4.37"/>
                        <!-- Including assigningAuthorityName is a best practice but not required --> 
                        <id assigningAuthorityName="FDA" extension="(01)00848486001032(11)160330(10)ABC124" root="2.16.840.1.113883.3.3719"/>
                        <playingDevice>
                            <code nullFlavor="UNK">
                                <originalText>
                                    <reference value="#implant2"/>
                                </originalText>
                            </code>
                        </playingDevice>
                        <!-- From Product Instance template:
                 The scopingEntity/id should correspond to FDA or the appropriate issuing agency. -->
                        <scopingEntity>
                            <id root="2.16.840.1.113883.3.3719"/>
                        </scopingEntity>
                    </participantRole>
                </participant>
            </procedure>
        </entry>
        <entry>
            <procedure classCode="PROC" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
                <templateId root="2.16.840.1.113883.10.20.22.4.14"/>
                <id extension="2746" root="1.2.840.114350.1.13.5552.1.7.2.737780"/>
                <code nullFlavor="UNK"/>
                <statusCode code="completed"/>
                <effectiveTime>
                    <low value="20160413"/>
                </effectiveTime>
                <!-- Example where targetSiteCode is not mapped -->
                <targetSiteCode nullFlavor="UNK">
                    <originalText>
                        <reference value="#implant3site" />
                    </originalText>
                </targetSiteCode>
                <participant typeCode="DEV">
                    <participantRole classCode="MANU">
                        <templateId root="2.16.840.1.113883.10.20.22.4.37"/>
                        <id assigningAuthorityName="FDA" extension="(01)00848486000349(11)160330(10)ABC721" root="2.16.840.1.113883.3.3719"/>
                        <playingDevice>
                            <code nullFlavor="UNK">
                                <originalText>
                                    <reference value="#implant3"/>
                                </originalText>
                            </code>
                        </playingDevice>
                        <!-- From Product Instance template:
                 The scopingEntity/id should correspond to FDA or the appropriate issuing agency. -->
                        <scopingEntity>
                            <id root="2.16.840.1.113883.3.3719"/>
                        </scopingEntity>
                    </participantRole>
                </participant>
            </procedure>
        </entry>
    </section>
</component>

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