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| Official URL: http://hl7.org/cda/us/ccda/StructureDefinition/ProcedureDescriptionSection | Version: 3.0.0 | |||
| Draft as of 2024-05-18 | Computable Name: ProcedureDescriptionSection | |||
| Other Identifiers: OID:2.16.840.1.113883.10.20.22.2.27 | ||||
The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty.
Usage:
Description of Template, Differentials, Snapshots and how the different presentations work.
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
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Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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0..0 | |||
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1..1 | CE | Procedure Narrative | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
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1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
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1..1 | CE | Procedure Narrative Binding: DocumentSectionType (example) | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
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1..1 | ST | ||
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1..1 | xhtml | ||
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |
Differential View
This structure is derived from Section
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | ||
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
![]() ![]() ![]() ![]() |
0..0 | |||
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1..1 | CE | Procedure Narrative | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints![]() |
|---|---|---|---|---|
![]() |
1..1 | Section | XML Namespace: urn:hl7-org:v3 Elements defined in Ancestors:@nullFlavor, realmCode, typeId, templateId, @ID, @classCode, @moodCode, id, code, title, text, confidentialityCode, languageCode, subject, author, informant, entry, component Base for all types and resources Instance of this type are validated by templateId Logical Container: ClinicalDocument (CDA Class) | |
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1..* | II | Slice: Unordered, Open by value:root | |
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1..1 | II | ||
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.10.20.22.2.27 | |
![]() ![]() |
1..1 | CE | Procedure Narrative Binding: DocumentSectionType (example) | |
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1..1 | cs | Required Pattern: 29554-3 | |
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1..1 | oid, uuid, ruid | Required Pattern: 2.16.840.1.113883.6.1 | |
![]() ![]() |
1..1 | ST | ||
![]() ![]() |
1..1 | xhtml | ||
Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType |
Snapshot View
| Path | Conformance | ValueSet / Code | URI |
| Section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.templateId:section.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.classCode | required | Fixed Value: DOCSECThttp://terminology.hl7.org/ValueSet/v3-ActClassRecordOrganizer | |
| Section.moodCode | required | Fixed Value: EVNhttp://hl7.org/cda/stds/core/ValueSet/CDAActMood | |
| Section.code | example | DocumentSectionTypehttp://terminology.hl7.org/ValueSet/v3-DocumentSectionType | |
| Section.code.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.languageCode | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languagesfrom the FHIR Standard | |
| Section.component.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor | |
| Section.component.typeId.nullFlavor | required | CDANullFlavorhttp://hl7.org/cda/stds/core/ValueSet/CDANullFlavor |