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  1. CDA Specification Feedback
  2. CDA-1997

STU-1997 - Procedures

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    • Icon: Change Request Change Request
    • Resolution: Persuasive
    • Icon: Medium Medium
    • C-CDA Templates Clinical Notes (CDA)
    • Structured Documents
    • Templates [deprecated]
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      2.61.1 Procedures Section (entries required) (V2)
      1) From: This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated.
      To: This section describes all historical or current interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient at the time the document is generated.

      2) Require effectiveTime inProcedure Activity Procedure (V2) (optional) (Currently SHOULD) Procedure Activity Observation (V2) (optional) (Currently SHOULD)

      3) Add primitive computable conformance statements to effectiveTime to restrict effective time to procedures either completed or still in progress at the time of document generation in: Procedure Activity Act (V2) (optional) (Currently SHALL) Procedure Activity Procedure (V2) (optional) (Currently SHOULD) Procedure Activity Observation (V2) (optional) (Currently SHOULD) Conformance statements that will need associated additional primitive statements: Procedure Activity Act (V2) CONF:1098-8299 Procedure Activity Procedure (V2) CONF:1098-7662 Procedure Activity Observation (V2) CONF:1098-8246 If an entry effectiveTime/@value or effectiveTime/low/@value is present, then it must be equal to or before the document header effectiveTime. If an entry effectiveTime/high/@value is present and the entry statusCode is “active” then it must be after the document header effectiveTime

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      2.61.1 Procedures Section (entries required) (V2) 1) From: This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. To: This section describes all historical or current interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient at the time the document is generated. 2) Require effectiveTime inProcedure Activity Procedure (V2) (optional) (Currently SHOULD) Procedure Activity Observation (V2) (optional) (Currently SHOULD) 3) Add primitive computable conformance statements to effectiveTime to restrict effective time to procedures either completed or still in progress at the time of document generation in: Procedure Activity Act (V2) (optional) (Currently SHALL) Procedure Activity Procedure (V2) (optional) (Currently SHOULD) Procedure Activity Observation (V2) (optional) (Currently SHOULD) Conformance statements that will need associated additional primitive statements: Procedure Activity Act (V2) CONF:1098-8299 Procedure Activity Procedure (V2) CONF:1098-7662 Procedure Activity Observation (V2) CONF:1098-8246 If an entry effectiveTime/@value or effectiveTime/low/@value is present, then it must be equal to or before the document header effectiveTime. If an entry effectiveTime/high/@value is present and the entry statusCode is “active” then it must be after the document header effectiveTime
    • Jean Duteau / Brett Marquard : 15-0-0
    • Enhancement
    • Compatible, substantive

    Description

      Specification - Extended

      HL7 CDA® R2 IG: C-CDA Templates for Clinical Notes DSTU Release 2.1 - US Realm

      Document Description

      extended per extended per TSC tracker 12437, again with 14128 and jira.hl7.org/browse/TSC-38

      Existing Wording

      2.61 Procedures Section (entries optional) (V2) 2.61.1 Procedures Section (entries required) (V2) I think we have a discrepancy between the narrative text in these sections versus the formal constraints on the contained "Procedure Activity Procedure (V2)" entry template. The sections are only supposed to contain historical procedures which actually altered the patient's state. However the Value Set: ProcedureAct statusCode urn:oid:2.16.840.1.113883.11.20.9.22 includes concept codes for "aborted", "active", and "cancelled". If the procedure is still active then it isn't yet historical. If the procedure was aborted or cancelled then presumably it didn't alter the patient state. This is creating confusion among implementers. We have received documents from multiple EHRs containing procedure entries with statusCode/@code="active".

      Proposed Wording

      Create a new "Historical Procedure Activity Procedure" entry template which is the same as the "Procedure Activity Procedure (V2)" entry template but with a static statusCode/@code="completed". Or alternatively, add new constraints to the "Procedures Section (entries optional) (V2)" and "Procedures Section (entries required) (V2)" section templates to require that any contained "Historical Procedure Activity Procedure" have a static statusCode/@code="completed".

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            benjamin Benjamin Flessner
            nradov Nick Radov
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            Dates

              Created:
              Updated:
              Resolved: