Details
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Change Request
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Resolution: Persuasive with Modification
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Medium
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C-CDA Templates Clinical Notes (CDA)
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2.1.0.6 [deprecated]
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Structured Documents
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Templates [deprecated]
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Russell Ott / Sean McIlvenna : 8-0-1
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Correction
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Compatible, substantive
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2.1.0.7 [deprecated]
Description
Currently the Operative Note document template has the following primitive constraint for documentationOf/serviceEvent/code, and no modelled constraint for the serviceEvent/code element:
The value of 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:1198-8487).
In accordance with similar updates to Procedure Note and Procedure Activity Act/Observation/Procedure templates, we should add a "parent" constraint for the serviceEvent/code element, and update the existing conformance statement to be as follows:
- This serviceEvent MAY contain zero or one [0..1] code (CONF:XXXX).
- The value of serviceEvent/code SHALL be selected from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (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 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).