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

Procedure Note

[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.6]

Procedure Note Header Constraints

Procedure Note Body Constraints

  1. SHALL contain exactly one [1..1] templateId ( CONF:8496, CONF:10050 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.6"
  2. SHALL conform to General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1) (CONF:9969, CONF:10049)
  3. SHALL contain exactly one [1..1] code (CONF:17182), where the @code SHALL be selected from ValueSet ProcedureNoteDocumentTypeCodes 2.16.840.1.113883.11.20.6.1 DYNAMIC (CONF:17183)
  4. SHOULD contain zero or one [0..1] componentOf (CONF:8499)
    1. This componentOf SHOULD contain zero or one [0..1] encompassingEncounter (CONF:8501)
      1. This encompassingEncounter SHALL contain at least one [1..*] location
        1. Such locations SHALL contain at least one [1..*] healthCareFacility
          1. Such healthCareFacilitys SHALL contain at least one [1..*] id (b., CONF:8500)
      2. This encompassingEncounter MAY contain zero or one [0..1] encounterParticipant (CONF:8502)
        1. This encounterParticipant SHALL contain exactly one [1..1] @typeCode="REF" (CONF:8503)
      3. This encompassingEncounter SHALL contain exactly one [1..1] code (CONF:8501)
  5. MAY contain zero or one [0..1] component (CONF:9645)
    1. Contains exactly one [1..1] Assessment Section (templateId: 2.16.840.1.113883.10.20.22.2.8)
  6. MAY contain zero or one [0..1] component (CONF:9647)
    1. Contains exactly one [1..1] Plan Of Care Section (templateId: 2.16.840.1.113883.10.20.22.2.10)
  7. MAY contain zero or one [0..1] component (CONF:9649)
    1. Contains exactly one [1..1] Assessment And Plan Section (templateId: 2.16.840.1.113883.10.20.22.2.9)
  8. SHALL contain exactly one [1..1] component (CONF:9802)
    1. Contains exactly one [1..1] Complications Section (templateId: 2.16.840.1.113883.10.20.22.2.37)
  9. SHALL contain exactly one [1..1] component (CONF:9850)
    1. Contains exactly one [1..1] Postprocedure Diagnosis Section (templateId: 2.16.840.1.113883.10.20.22.2.36)
  10. SHALL contain exactly one [1..1] component (CONF:9805)
    1. Contains exactly one [1..1] Procedure Description Section (templateId: 2.16.840.1.113883.10.20.22.2.27)
  11. SHALL contain exactly one [1..1] component (CONF:9807)
    1. Contains exactly one [1..1] Procedure Indications Section (templateId: 2.16.840.1.113883.10.20.22.2.29)
  12. MAY contain zero or one [0..1] component (CONF:9809)
    1. Contains exactly one [1..1] Allergies Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.6)
  13. MAY contain zero or one [0..1] component (CONF:9811)
    1. Contains exactly one [1..1] Anesthesia Section (templateId: 2.16.840.1.113883.10.20.22.2.25)
  14. MAY contain zero or one [0..1] component (CONF:9813)
    1. Contains exactly one [1..1] Chief Complaint Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1)
  15. MAY contain zero or one [0..1] component (CONF:9815)
    1. Contains exactly one [1..1] Chief Complaint And Reason For Visit Section (templateId: 2.16.840.1.113883.10.20.22.2.13)
  16. MAY contain zero or one [0..1] component (CONF:9817)
    1. Contains exactly one [1..1] Family History Section (templateId: 2.16.840.1.113883.10.20.22.2.15)
  17. MAY contain zero or one [0..1] component (CONF:9819)
    1. Contains exactly one [1..1] History Of Past Illness Section (templateId: 2.16.840.1.113883.10.20.22.2.20)
  18. MAY contain zero or one [0..1] component (CONF:9821)
    1. Contains exactly one [1..1] History Of Present Illness Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.4)
  19. MAY contain zero or one [0..1] component (CONF:9823)
    1. Contains exactly one [1..1] Medical History Section (templateId: 2.16.840.1.113883.10.20.22.2.39)
  20. MAY contain zero or one [0..1] component (CONF:9825)
    1. Contains exactly one [1..1] Medications Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.1)
  21. MAY contain zero or one [0..1] component (CONF:9827)
    1. Contains exactly one [1..1] Medications Administered Section (templateId: 2.16.840.1.113883.10.20.22.2.38)
  22. MAY contain zero or one [0..1] component (CONF:9829)
    1. Contains exactly one [1..1] Physical Exam Section (templateId: 2.16.840.1.113883.10.20.2.10)
  23. MAY contain zero or one [0..1] component (CONF:9831)
    1. Contains exactly one [1..1] Planned Procedure Section (templateId: 2.16.840.1.113883.10.20.22.2.30)
  24. MAY contain zero or one [0..1] component (CONF:9833)
    1. Contains exactly one [1..1] Procedure Disposition Section (templateId: 2.16.840.1.113883.10.20.18.2.12)
  25. MAY contain zero or one [0..1] component (CONF:9835)
    1. Contains exactly one [1..1] Procedure Estimated Blood Loss Section (templateId: 2.16.840.1.113883.10.20.18.2.9)
  26. MAY contain zero or one [0..1] component (CONF:9837)
    1. Contains exactly one [1..1] Procedure Findings Section (templateId: 2.16.840.1.113883.10.20.22.2.28)
  27. MAY contain zero or one [0..1] component (CONF:9839)
    1. Contains exactly one [1..1] Procedure Implants Section (templateId: 2.16.840.1.113883.10.20.22.2.40)
  28. MAY contain zero or one [0..1] component (CONF:9841)
    1. Contains exactly one [1..1] Procedure Specimens Taken Section (templateId: 2.16.840.1.113883.10.20.22.2.31)
  29. MAY contain zero or one [0..1] component (CONF:9843)
    1. Contains exactly one [1..1] Procedures Section Entries Optional (templateId: 2.16.840.1.113883.10.20.22.2.7)
  30. MAY contain zero or one [0..1] component (CONF:9845)
    1. Contains exactly one [1..1] Reason For Visit Section (templateId: 2.16.840.1.113883.10.20.22.2.12)
  31. MAY contain zero or one [0..1] component (CONF:9847)
    1. Contains exactly one [1..1] Review Of Systems Section (templateId: 1.3.6.1.4.1.19376.1.5.3.1.3.18)
  32. MAY contain zero or one [0..1] component (CONF:9849)
    1. Contains exactly one [1..1] Social History Section (templateId: 2.16.840.1.113883.10.20.22.2.17)
  33. MAY contain zero or more [0..*] participant (CONF:8504)
    1. Contains exactly one [1..1] CDA Participant1
  34. SHALL contain at least one [1..*] documentationOf (CONF:8510)
    1. Such documentationOfs SHALL contain exactly one [1..1] serviceEvent (CONF:10061)
      1. This serviceEvent SHALL contain exactly one [1..1] code (CONF:8511)
      2. This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:10062)
      3. This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8520)
        1. This performer SHALL contain exactly one [1..1] @typeCode="PPRF" (CONF:8521)
        2. This performer SHALL contain exactly one [1..1] assignedEntity (CONF:14911)
          1. This assignedEntity SHOULD contain zero or one [0..1] code (CONF:14912), where the @code SHALL be selected from ValueSet Healthcare Provider Taxonomy (NUCC - HIPAA) 2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:14913)
      4. This serviceEvent i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC. (CONF:8511)
      5. This serviceEvent The serviceEvent/effectiveTime SHALL be present with effectiveTime/low (CONF:8513)
      6. This serviceEvent If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high. (CONF:8514)
      7. This serviceEvent When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present. (CONF:8515)
      8. This serviceEvent Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF) (CONF:8524)
  35. SHALL include an Assessment and Plan Section, or an Assessment Section and a Plan Section (CONF:9643)
  36. SHALL NOT include an Assessment/Plan Section when an Assessment Section and a Plan of Care Section are present (CONF:10064)
  37. SHALL NOT include a Chief Complaint and Reason for Visit Section with either a Chief Complaint Section or a Reason for Visit Section. (CONF:10065)
  38. Each section SHALL have a title and the title SHALL NOT be empty (CONF:9937)

Procedure Note Example

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <typeId root="2.16.840.1.113883.1.3"/>
  <id root="MDHT" extension="1817317613"/>
  <code code="1666784493"/>
  <title>TEXT FOR TITLE</title>
  <effectiveTime/>
  <confidentialityCode code="2134336942"/>
  <setId root="MDHT" extension="defee4fb-2d43-4230-acd9-656c7630fa52"/>
  <versionNumber value="1"/>
  <recordTarget>
    <typeId root="2.16.840.1.113883.1.3"/>
    <patientRole/>
  </recordTarget>
  <author>
    <typeId root="2.16.840.1.113883.1.3"/>
    <time/>
    <assignedAuthor/>
  </author>
  <custodian/>
  <participant/>
  <documentationOf>
    <serviceEvent>
      <code code="1483772863"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <performer typeCode="PPRF"/>
    </serviceEvent>
  </documentationOf>
  <componentOf>
    <encompassingEncounter>
      <code code="579286959"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <encounterParticipant typeCode="REF"/>
      <location/>
    </encompassingEncounter>
  </componentOf>
  <component>
    <structuredBody>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="709251425"/>
          <code code="1544660639"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1790742558"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="114881766"/>
          <code code="1454047608"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1881221157"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1770360526"/>
              <code code="860637152"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
          <entry>
            <encounter>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1779916307"/>
              <code code="357104389"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </encounter>
          </entry>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="944142649"/>
              <code code="863800163"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </observation>
          </entry>
          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2043276667"/>
              <code code="1585331712"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </procedure>
          </entry>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2015451032"/>
              <code code="1527379975"/>
              <effectiveTime value="20130627"/>
              <consumable/>
            </substanceAdministration>
          </entry>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1679963671"/>
              <code code="505676005"/>
              <effectiveTime value="20130627"/>
            </supply>
          </entry>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="188062323"/>
              <code code="770936041"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1447176866"/>
          <code code="323890623"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1926707389"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2009400634"/>
              <code code="1072985794"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1060937152"/>
          <code code="1808417528"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="826003963"/>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1286817049"/>
              <code code="2049930553"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1866512692"/>
          <code code="182825062"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2118579604"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="486749498"/>
              <code code="2141790263"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="769732019"/>
          <code code="210272622"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="226431371"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="633226103"/>
          <code code="1133785885"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="131985795"/>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1323756789"/>
              <code code="79319003"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1320650915"/>
          <code code="1012801361"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1472239550"/>
          <entry>
            <act>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1019239808"/>
              <code code="2031201676"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1954768425"/>
          <code code="2040315366"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1241898448"/>
          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1925678582"/>
              <code code="1503391013"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <specimen/>
              <performer/>
              <entryRelationship typeCode="COMP" inversionInd="true"/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
            </procedure>
          </entry>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="221172663"/>
              <code code="1139895835"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="95906927"/>
          <code code="880726282"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="279597576"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="755392436"/>
          <code code="429386264"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="337251287"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1296679944"/>
          <code code="311424947"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="2074694547"/>
          <entry>
            <organizer>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1318875372"/>
              <code code="728588304"/>
              <statusCode code="completed"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <subject/>
              <component>
                <observation/>
              </component>
            </organizer>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1701256536"/>
          <code code="1445188473"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1276525459"/>
          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="341152205"/>
              <code code="1744296101"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="179348471"/>
          <code code="1929507883"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="560813911"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="319823979"/>
          <code code="1633126882"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="728583864"/>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="820338085"/>
          <code code="1647479542"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1077895617"/>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="966200078"/>
              <code code="87938109"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1463337817"/>
          <code code="867074571"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1582410858"/>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="758476188"/>
              <code code="430728406"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="1466998986"/>
          <code code="2085754837"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="93321412"/>
          <entry>
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