Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Procedure Activity Observation

[Observation: templateId 2.16.840.1.113883.10.20.22.4.13]

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 clinical statement represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.

  1. SHALL contain exactly one [1..1] templateId ( CONF:10520 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.4.13"
  2. SHALL contain exactly one [1..1] @classCode="OBS" Observation (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:8282)
  3. SHALL contain exactly one [1..1] @moodCode, where the @code SHALL be selected from ValueSet MoodCodeEvnInt 2.16.840.1.113883.11.20.9.18 STATIC 2011-04-03 (CONF:8237)
  4. SHALL contain at least one [1..*] id (CONF:8239)
  5. SHALL contain exactly one [1..1] code (CONF:8240)
  6. SHALL contain exactly one [1..1] statusCode, where the @code SHALL be selected from ValueSet ProcedureActStatusCode 2.16.840.1.113883.11.20.9.22 DYNAMIC (CONF:8245)
  7. SHALL contain exactly one [1..1] value (CONF:16846)
  8. SHOULD contain zero or one [0..1] effectiveTime (CONF:8246)
  9. MAY contain zero or one [0..1] priorityCode, where the @code SHALL be selected from ValueSet ActPriority 2.16.840.1.113883.1.11.16866 STATIC (CONF:8247)
  10. MAY contain zero or one [0..1] methodCode (CONF:8248)
  11. SHOULD contain zero or more [0..*] targetSiteCode (CONF:8250), where the @code SHALL be selected from ValueSet Body Site Value Set 2.16.840.1.113883.3.88.12.3221.8.9 STATIC 2 (CONF:10121)
  12. SHOULD contain zero or more [0..*] performer (CONF:8251)
    1. Such performers SHALL contain exactly one [1..1] assignedEntity (CONF:8252)
      1. This assignedEntity SHALL contain at least one [1..*] id (CONF:8253)
      2. This assignedEntity SHALL contain exactly one [1..1] addr (CONF:8254)
      3. This assignedEntity SHALL contain exactly one [1..1] telecom (CONF:8255)
      4. This assignedEntity SHOULD contain zero or one [0..1] representedOrganization (CONF:8256)
        1. This representedOrganization SHOULD contain zero or more [0..*] id (CONF:8257)
        2. This representedOrganization MAY contain zero or more [0..*] name (CONF:8258)
        3. This representedOrganization SHALL contain exactly one [1..1] telecom (CONF:8260)
        4. This representedOrganization SHALL contain exactly one [1..1] addr (CONF:8259)
  13. MAY contain zero or more [0..*] participant (CONF:8261, CONF:8262, CONF:15904)
    1. Contains exactly one [1..1] Service Delivery Location (templateId: 2.16.840.1.113883.10.20.22.4.32)
  14. MAY contain zero or one [0..1] entryRelationship (CONF:8272, CONF:8273, CONF:15905)
    1. Contains @typeCode="SUBJ" SUBJ
    2. Contains exactly one [1..1] Instructions (templateId: 2.16.840.1.113883.10.20.22.4.20)
  15. MAY contain zero or more [0..*] entryRelationship (CONF:8276, CONF:8277, CONF:15906)
    1. Contains @typeCode="RSON" RSON
    2. Contains exactly one [1..1] Indication (templateId: 2.16.840.1.113883.10.20.22.4.19)
  16. MAY contain zero or one [0..1] entryRelationship (CONF:8279, CONF:8280, CONF:15907)
    1. Contains @typeCode="COMP" COMP
    2. Contains exactly one [1..1] Medication Activity (templateId: 2.16.840.1.113883.10.20.22.4.16)
  17. MAY contain zero or more [0..*] entryRelationship (CONF:8264)
    1. Such entryRelationships SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8266)
    2. Such entryRelationships SHALL contain exactly one [1..1] @typeCode="COMP" (CONF:8265)
    3. Such entryRelationships SHALL contain exactly one [1..1] encounter (CONF:8267)
      1. This encounter SHALL contain exactly one [1..1] @classCode="ENC" (CodeSystem: 2.16.840.1.113883.5.6 HL7ActClass) (CONF:8268)
      2. This encounter SHALL contain exactly one [1..1] @moodCode="EVN" Event (CodeSystem: 2.16.840.1.113883.5.1001 HL7ActMood) (CONF:8269)
      3. This encounter SHALL contain exactly one [1..1] id (CONF:8270)
      4. This encounter MAY satisfy: Set the encounter ID to the ID of an encounter in another section to signify they are the same encounter. (CONF:16847)
  18. code in a procedure activity SHOULD be selected from LOINC (codeSystem 2.16.840.1.113883.6.1) or SNOMED CT (codeSystem 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (codeSystem 2.16.840.1.113883.6.12), ICD9 Procedures (codeSystem 2.16.840.1.113883.6.4) (CONF:8241)
  19. code SHOULD contain zero or one [0..1] originalText (CONF:8242)
  20. originalText, if present, SHOULD contain zero or one [0..1] reference (CONF:15901)
  21. reference, if present, SHOULD contain zero or one [0..1] @value (CONF:15902)
  22. 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:15903)
  23. methodCode SHALL NOT conflict with the method inherent in Procedure / code (CONF:8249)
  24. entryRelationship with target class encounter SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8266)
  25. participant with target class Service Delivery Location SHALL contain exactly one [1..1] @typeCode="LOC" Location (CodeSystem: 2.16.840.1.113883.5.1002 HL7ActRelationshipType) STATIC (CONF:8262)
  26. entryRelationship with target class Instructions SHALL contain exactly one [1..1] @inversionInd="true" (CONF:8274)

Procedure Activity Observation example

<observation xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3">
  <id root="MDHT" extension="1185898330"/>
  <code code="2049512593"/>
  <effectiveTime>
    <low value="2013"/>
    <high value="2013"/>
  </effectiveTime>
  <priorityCode code="1212638397"/>
  <methodCode code="416350032"/>
  <targetSiteCode code="1023955922"/>
  <performer>
    <assignedEntity>
      <id root="MDHT" extension="566079751"/>
      <addr/>
      <telecom/>
      <representedOrganization/>
    </assignedEntity>
  </performer>
  <entryRelationship typeCode="COMP" inversionInd="true">
    <encounter classCode="ENC" moodCode="EVN">
      <id root="MDHT" extension="477349399"/>
    </encounter>
  </entryRelationship>
  <entryRelationship>
    <act>
      <id root="MDHT" extension="733087609"/>
      <code code="1825140587"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <priorityCode code="1673446340"/>
    </act>
  </entryRelationship>
  <entryRelationship>
    <observation>
      <id root="MDHT" extension="1610820046"/>
      <code code="1980432434"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <priorityCode code="1437121100"/>
      <value xsi:type="CD" code="2010905351"/>
      <methodCode code="223289314"/>
      <targetSiteCode code="1988213056"/>
    </observation>
  </entryRelationship>
  <entryRelationship>
    <substanceAdministration>
      <id root="MDHT" extension="535374660"/>
      <code code="95891606"/>
      <effectiveTime value="20130627"/>
      <priorityCode code="873567683"/>
      <consumable>
        <manufacturedProduct/>
      </consumable>
      <performer/>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="2047189129"/>
          <code code="627076509"/>
          <effectiveTime value="20130627"/>
          <priorityCode code="1204128689"/>
          <author/>
          <entryRelationship>
            <act/>
          </entryRelationship>
        </supply>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="247556536"/>
          <code code="1700855090"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="1176867592"/>
          <value xsi:type="CD" code="802614419"/>
          <methodCode code="2141378027"/>
          <targetSiteCode code="1049513417"/>
          <entryRelationship>
            <observation/>
          </entryRelationship>
          <entryRelationship>
            <procedure/>
          </entryRelationship>
          <entryRelationship>
            <substanceAdministration/>
          </entryRelationship>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <act>
          <id root="MDHT" extension="24524767"/>
          <code code="377328747"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="234093590"/>
        </act>
      </entryRelationship>
      <entryRelationship>
        <observation>
          <id root="MDHT" extension="150611848"/>
          <code code="1155629849"/>
          <effectiveTime>
            <low value="2013"/>
            <high value="2013"/>
          </effectiveTime>
          <priorityCode code="1635765326"/>
          <value xsi:type="CD" code="963158793"/>
          <methodCode code="386712139"/>
          <targetSiteCode code="1211809443"/>
        </observation>
      </entryRelationship>
      <entryRelationship>
        <supply>
          <id root="MDHT" extension="955297466"/>
          <code code="1624194976"/>
          <effectiveTime value="20130627"/>
          <priorityCode code="1935468709"/>
          <performer/>
          <entryRelationship>
            <supply/>
          </entryRelationship>
        </supply>
      </entryRelationship>
      <precondition>
        <criterion/>
      </precondition>
    </substanceAdministration>
  </entryRelationship>
</observation>