Procedures Section (entries required) (V2)
OID: 2.16.840.1.113883.10.20.22.2.7.1
LOINCs: #{"47519-4"}
Alias: procedures
Entries Required: true
Internal ID: ProceduresSectionentriesrequiredV
Procedure example.
This is a typical procedure resource sample.
:performed field contains information about start and end dates of procedure.
:bodySite field contains information about body site of procedure.
:status field contains information about status of procedure.
In this case it is used to distinguish procedure from other acts like observation or even any act in common.
{
"extension" : [ {
"url" : "rim-class",
"value" : {
"code" : "procedure"
}
} ],
"id" : "64af26d5-88ef-4169-ba16-c6ef16a1824f",
"code" : {
"coding" : [ {
"code" : "6025007",
"display" : "Laparoscopic appendectomy",
"system" : "http://snomed.info/sct"
}, {
"code" : "44970",
"display" : "Laparoscopic Appendectomy",
"system" : "http://www.ama-assn.org/go/cpt"
}, {
"code" : "0DTJ4ZZ",
"display" : "Resection of Appendix, Percutaneous Endoscopic Approach",
"system" : "urn:oid:2.16.840.1.113883.6.4"
}, {
"code" : "47.01",
"display" : "Laparoscopic appendectomy",
"system" : "http://hl7.org/fhir/sid/icd-9-cm"
} ]
},
"performed" : {
"Period" : {
"start" : "2014-02-03T09:22:05-07:00",
"end" : "2014-02-03T11:15:14-07:00"
}
},
"status" : "completed",
"bodySite" : [ {
"coding" : [ {
"code" : "181255000",
"display" : "Entire Appendix",
"system" : "http://snomed.info/sct"
} ]
} ],
"resourceType" : "Procedure",
"subject" : {
"id" : "patient",
"resourceType" : "Patient"
}
}C-CDA Equivalent:
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code codeSystem="2.16.840.1.113883.6.1"
codeSystemName="http://loinc.org"
displayName="display string"
code="47519-4"/>
<title>Procedures Section (entries required) (V2)</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Procedures</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Laparoscopic appendectomy</td>
<td>02/03/2014 4:22PM UTC - 02/03/2014 6:15PM UTC</td>
<td>completed</td>
</tr>
</tbody>
</table>
</text>
<entry>
<procedure moodCode="EVN" classCode="PROC">
<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
<id root="64af26d5-88ef-4169-ba16-c6ef16a1824f"/>
<code codeSystem="2.16.840.1.113883.6.96"
codeSystemName="http://snomed.info/sct"
displayName="Laparoscopic appendectomy"
code="6025007">
<translation codeSystem="2.16.840.1.113883.6.12"
codeSystemName="http://www.ama-assn.org/go/cpt"
displayName="Laparoscopic Appendectomy"
code="44970"/>
<translation codeSystem="2.16.840.1.113883.6.4"
codeSystemName="urn:oid:2.16.840.1.113883.6.4"
displayName="Resection of Appendix, Percutaneous Endoscopic Approach"
code="0DTJ4ZZ"/>
<translation codeSystem="2.16.840.1.113883.6.104"
codeSystemName="http://hl7.org/fhir/sid/icd-9-cm"
displayName="Laparoscopic appendectomy"
code="47.01"/>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20140203092205-0700"/>
<high value="20140203111514-0700"/>
</effectiveTime>
<methodCode nullFlavor="UNK"/>
<targetSiteCode codeSystem="2.16.840.1.113883.6.96"
codeSystemName="http://snomed.info/sct"
displayName="Entire Appendix"
code="181255000"/>
</procedure>
</entry>
</section>Procedure Act example.
Th converter rules don't use :extension field to distinguish Procedure Act from other acts, but you can add related rules to do it.
In this case :extension field is used to distinguish more common procedure act like patient education.
{
"extension" : [ {
"url" : "rim-class",
"value" : {
"code" : "act"
}
} ],
"id" : "9c0f070c-2e9e-4be1-a5b5-ff6d0f68123c",
"code" : {
"coding" : [ {
"code" : "61310001",
"display" : "Nutrition education",
"system" : "http://snomed.info/sct"
}, {
"code" : "97802",
"display" : "Medical nutrition therapy; initial",
"system" : "http://www.ama-assn.org/go/cpt"
}, {
"code" : "S9470",
"display" : "Nutritional counseling, diet",
"system" : "urn:oid:2.16.840.1.113883.6.13"
}, {
"code" : "V65.3",
"display" : "Dietary surveillance and counseling",
"system" : "urn:oid:2.16.840.1.113883.6.103"
}, {
"code" : "Z71.3",
"display" : "Dietary counseling and surveillance",
"system" : "http://hl7.org/fhir/sid/icd-10"
} ]
},
"performed" : {
"dateTime" : "2014-03-29T10:45:13-05:00"
},
"status" : "completed",
"resourceType" : "Procedure",
"subject" : {
"id" : "patient",
"resourceType" : "Patient"
}
}The section contains an Act entry converted from the input Procedure resource.
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code codeSystem="2.16.840.1.113883.6.1"
codeSystemName="http://loinc.org"
displayName="display string"
code="47519-4"/>
<title>Procedures Section (entries required) (V2)</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Procedures</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>Nutrition education</td>
<td>03/29/2014 3:45PM UTC</td>
<td>completed</td>
</tr>
</tbody>
</table>
</text>
<entry>
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.12" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
<id root="9c0f070c-2e9e-4be1-a5b5-ff6d0f68123c"/>
<code codeSystem="2.16.840.1.113883.6.96"
codeSystemName="http://snomed.info/sct"
displayName="Nutrition education"
code="61310001">
<translation codeSystem="2.16.840.1.113883.6.12"
codeSystemName="http://www.ama-assn.org/go/cpt"
displayName="Medical nutrition therapy; initial"
code="97802"/>
<translation codeSystem="2.16.840.1.113883.6.13"
codeSystemName="urn:oid:2.16.840.1.113883.6.13"
displayName="Nutritional counseling, diet"
code="S9470"/>
<translation codeSystem="2.16.840.1.113883.6.103"
codeSystemName="urn:oid:2.16.840.1.113883.6.103"
displayName="Dietary surveillance and counseling"
code="V65.3"/>
<translation codeSystem="2.16.840.1.113883.6.90"
codeSystemName="http://hl7.org/fhir/sid/icd-10"
displayName="Dietary counseling and surveillance"
code="Z71.3"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="20140329104513-0500"/>
</act>
</entry>
</section>Procedure Observation example.
Like the previous examples, this is a typical Procedure resource sample.
{
"extension" : [ {
"url" : "rim-class",
"value" : {
"code" : "observation"
}
} ],
"id" : "c03e5445-af1b-4911-a419-e2782f21448c",
"code" : {
"coding" : [ {
"code" : "268400002",
"display" : "12 lead ECG",
"system" : "http://snomed.info/sct"
}, {
"code" : "93000",
"display" : "Electrocardiogram, complete",
"system" : "http://www.ama-assn.org/go/cpt"
}, {
"code" : "G8704",
"display" : "12-Lead Electrocardiogram (Ecg) Performed",
"system" : "urn:oid:2.16.840.1.113883.6.13"
}, {
"code" : "89.52",
"display" : "Electrocardiogram",
"system" : "http://hl7.org/fhir/sid/icd-9-cm"
}, {
"code" : "4A02X4Z",
"display" : "Measurement of Cardiac Electrical Activity, External Approach",
"system" : "urn:oid:2.16.840.1.113883.6.4"
} ]
},
"performed" : {
"dateTime" : "2014-03-29T09:15:22-12:00"
},
"status" : "completed",
"resourceType" : "Procedure",
"subject" : {
"id" : "patient",
"resourceType" : "Patient"
}
}C-CDA Equivalent:
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
<code codeSystem="2.16.840.1.113883.6.1"
codeSystemName="http://loinc.org"
displayName="display string"
code="47519-4"/>
<title>Procedures Section (entries required) (V2)</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>Procedures</th>
<th>Date</th>
<th>Status</th>
</tr>
</thead>
<tbody>
<tr>
<td>12 lead ECG</td>
<td>03/29/2014 9:15PM UTC</td>
<td>completed</td>
</tr>
</tbody>
</table>
</text>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.13" extension="2014-06-09"/>
<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
<id root="c03e5445-af1b-4911-a419-e2782f21448c"/>
<code codeSystem="2.16.840.1.113883.6.96"
codeSystemName="http://snomed.info/sct"
displayName="12 lead ECG"
code="268400002">
<translation codeSystem="2.16.840.1.113883.6.12"
codeSystemName="http://www.ama-assn.org/go/cpt"
displayName="Electrocardiogram, complete"
code="93000"/>
<translation codeSystem="2.16.840.1.113883.6.13"
codeSystemName="urn:oid:2.16.840.1.113883.6.13"
displayName="12-Lead Electrocardiogram (Ecg) Performed"
code="G8704"/>
<translation codeSystem="2.16.840.1.113883.6.104"
codeSystemName="http://hl7.org/fhir/sid/icd-9-cm"
displayName="Electrocardiogram"
code="89.52"/>
<translation codeSystem="2.16.840.1.113883.6.4"
codeSystemName="urn:oid:2.16.840.1.113883.6.4"
displayName="Measurement of Cardiac Electrical Activity, External Approach"
code="4A02X4Z"/>
</code>
<statusCode code="completed"/>
<effectiveTime value="20140329091522-1200"/>
<value xsi:type="CD"/>
</observation>
</entry>
</section>Last updated