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

Procedures Section

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section is intended to include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change).
The length of an encounter is documented in the documentationOf/encompassingEncounter/effectiveTime and length of service in documentationOf/ServiceEvent/effectiveTime.

This section defines all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section is intended to include notable procedures, but can contain all procedures for the period of time being summarized. The common notion of "procedure" is broader than that specified by the HL7 Version 3 Reference Information Model (RIM). Therefore this section contains procedure templates represented with three RIM classes: Act. Observation, and Procedure. Procedure act is for procedures the alter that physical condition of a patient (Splenectomy). Observation act is for procedures that result in new information about a patient but do not cause physical alteration (EEG). Act is for all other types of procedures (dressing change).
The length of an encounter is documented in the documentationOf/encompassingEncounter/effectiveTime and length of service in documentationOf/ServiceEvent/effectiveTime.

Optional Entries

[Section: templateId 2.16.840.1.113883.10.20.22.2.7]

The following constraints apply to a Procedures Section in which entries are not required.

  1. SHALL contain exactly one [1..1] templateId ( CONF:6271 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.7"
  2. SHALL contain exactly one [1..1] code (CONF:15423)/@code="47519-4" History of Procedures (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:15424)
  3. SHALL contain exactly one [1..1] title (CONF:17184)
  4. SHALL contain exactly one [1..1] text (CONF:6273)
  5. MAY contain zero or more [0..*] entry (CONF:6274, CONF:15509)
    1. Contains exactly one [1..1] Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14)
  6. MAY contain zero or more [0..*] entry (CONF:6278, CONF:15510)
    1. Contains exactly one [1..1] Procedure Activity Observation (templateId: 2.16.840.1.113883.10.20.22.4.13)
  7. MAY contain zero or more [0..*] entry (CONF:8533, CONF:15511)
    1. Contains exactly one [1..1] Procedure Activity Act (templateId: 2.16.840.1.113883.10.20.22.4.12)

Required Entries

The following constraints apply to a Procedures Section in which entries are required.

  1. SHALL contain exactly one [1..1] templateId ( CONF:10447 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.7.1"
  2. SHALL conform to Procedures Section Entries Optional template (templateId: 2.16.840.1.113883.10.20.22.2.7)
  3. SHALL contain exactly one [1..1] title (CONF:7893)
  4. SHALL contain exactly one [1..1] code (CONF:15425)/@code="47519-4" History of procedures (CodeSystem: 2.16.840.1.113883.6.1 LOINC) (CONF:15426)
  5. SHALL contain exactly one [1..1] text (CONF:7894)
  6. MAY contain zero or more [0..*] entry (CONF:7895, CONF:7896)
    1. Contains exactly one [1..1] Procedure Activity Procedure (templateId: 2.16.840.1.113883.10.20.22.4.14)
  7. MAY contain zero or more [0..*] entry (CONF:8017, CONF:8018)
    1. Contains exactly one [1..1] Procedure Activity Observation (templateId: 2.16.840.1.113883.10.20.22.4.13)
  8. MAY contain zero or more [0..*] entry (CONF:8019, CONF:8020)
    1. Contains exactly one [1..1] Procedure Activity Act (templateId: 2.16.840.1.113883.10.20.22.4.12)
  9. There SHALL be at least one procedure, observation or act entry conformant to Procedure Activity Procedure template, Procedure Activity Observation template or Procedure Activity Act template in the Procedure Section. (CONF:8021)