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Please sign up if you do not have an account. C-CDA Online Navigator last updated: August 2023.The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore procedure templates can be represented with various RIM classes: act (e.g., dressing change), observation (e.g., EEG), procedure (e.g., splenectomy).This template represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement, and a creation of a gastrostomy.This template can be used with a contained Product Instance template to represent a device in or on a patient. In this case, targetSiteCode is used to record the location of the device in or on the patient's body. Equipment supplied to the patient (e.g., pumps, inhalers, wheelchairs) is represented by the Non-Medicinal Supply Activity (V2) template.Procedure Activity Procedure V3 Usage Note: Common practice in the industry has shown that Procedure Activity Procedure is the usually implemented CDA template for any type of intervention or procedure regardless of if the "immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient" or not. As a result, it is recommended to use Procedure Activity Procedure when sending procedures also thought of as "interventions" such as "Home Environment Evaluation" or "Assessment of nutritional status".
This reference/@value SHALL begin with a '#' and SHALL point to its corresponding narrative (using the approach defined in CDA Release 2, section 4.3.5.1) (CONF:4515-19206).
This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) OR SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96) OR CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) OR ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or HCPCS (Code System: 2.16.840.1.113762.1.4.1247.9) OR CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:4515-19207).
If the Intervention Procedure is a Social Determinant of Health Intervention, the procedure code SHOULD be selected from ValueSet Social Determinant of Health Procedures 2.16.840.1.113762.1.4.1196.789DYNAMIC (CONF:4515-32984).
MethodCode SHALL NOT conflict with the method inherent in Procedure / code (CONF:4515-7890).
In the case of an implanted medical device, targetSiteCode is used to record the location of the device, in
or on the patient's body.
If you want to indicate that the Procedure and the Results are referring to the same specimen, the Procedure/specimen/specimenRole/id SHOULD be set to equal an Organizer/specimen/ specimenRole/id (CONF:4515-29744).
This specimen is for representing specimens obtained from a procedure (CONF:4515-16842).
Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter (CONF:4515-16843).
When an Assessment Scale Observation is contained in a Procedure Template instance that is a Social
Determinant of Health intervention procedure, that Assessment scale MAY contain Assessment Scale
observations that represent LOINC question and answer pairs from SDOH screening instruments.
When an Entry Reference Template is contained in a Procedure Template instance that is a Social Determinant
of Health procedure, that Entry Reference MAY refer to Assessment Scale Observation in the same
document that represent LOINC question and answer pairs from SDOH screening instruments.