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The Procedures section details all interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated. The section should include notable procedures, but can contain all procedures for the period of time being summarized. There is a separate Entry section for each procedure.

This topic details the data elements that must be present in the Procedure section of a Continuity of Care Document (CCD) for it to be processed in the Clinical:ProcedureCcda data space (hosted in Data Engine).

(R) - Required elements for the Procedure section and its sub-sections to be processed correctly in the Clinical:ProcedureCcda data space.

(O) - Optional elements that are processed if provided in correct format.

Required (R) elements that are children of an Optional (O) element are only required for the immediate parent element to be processed.

Procedure Section Details

Procedure Section Template ID

component/section/templateId

Specifies which CCDA R2.1 template is being used to determine the requirements, format and structure of the information this subsection.

...
<component>
	<section>
		<templateId root=”2.16.840.1.113883.10.20.22.2.7.1”/>
	</section>
</component>
...
SectionElementAttributeValueNotes
ProceduretemplateIdrootMust be 2.16.840.1.113883.10.20.22.2.7.1The unique identifier for the CCDA R2.1 template that defines the requirements, format and structure for the entire Procedure section in Continuity of Care Documents (CCDs).

Procedure Section Code

component/section/code

Indicates that this section is detailing procedural information.

...
<component>
    <section>
        <templateId root=”2.16.840.1.113883.10.20.22.2.7.1”/>
		<code code="47519-4" codeSystem "2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURES"/>
    </section>
</component>
...
SectionElementAttributeValueNotes
ProcedurecodecodeMust be 47519-4In the Logical Observation Identifiers Names and Codes (LOINC) coding system this alphanumeric string (or 'code') represents the Procedures document.
codeSystemMust be 2.16.840.1.113883.6.1The unique numerical identifier for the Logical Observation Identifiers Names and Codes (LOINC) coding system. This system will be used to resolve the value in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the template section.

Procedure Section Author

component/section/author

Specifies information about the author of the document. Refer to Assigned Author Element for more details on what information can be available for the author section. 

...
<component>
    <section>
        <templateId root=”2.16.840.1.113883.10.20.22.2.7.1”/>
		<author>
			<assignedAuthor>
				...
			</assignedAuthor>
		</author>
    </section>
</component>
...

Procedure Section Confidentiality Code

component/section/confidentialityCode

Indicates the level of security that should be applied to this Procedure section. The level of security that should be applied is typically driven by the guidelines of the system that generated the CCD.

...
<component>
    <section>
        <templateId root=”2.16.840.1.113883.10.20.22.2.7.1”/>
		<confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/>
    </section>
</component>
...
SectionElementAttributeValueNotes
Procedure
confidentialityCode
codeMust include an alphanumeric string of any length. The HL7-supported confidentiality coding system is typically used, where security levels are indicated as:
  • U - unrestricted
  • L - low
  • N - normal
  • - moderate
  • R - restricted
  • V - very restricted

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust include an alphanumeric string of any length, typically in the following format: 2.16.840.1.113883.X.XX.X. The HL7-supported confidentiality coding system is indicated by 2.16.840.1.113883.5.25A numerical string that specifies which system will be used to translate the identifier provided in the code attribute.

Procedure Activity Procedure

component/section/entry/procedure

This section describes procedures that alter the physical condition of a patient (for example, a hip replacement or an appendectomy).

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				...
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure

procedure

classCodeMust be PROCSpecifies the general nature of the entry, which in this case is a procedure (PROC).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing act, or was documented from a past act.

Procedure Activity Procedure Template ID

component/section/entry/procedure/templateId

Specifies which CCDA R2.1 template is being used to structure the procedure activity procedure sub-section. R2.1 templates define the requirements, format, and structure of a CCD section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure

templateId

rootMust be 2.16.840.1.113883.10.20.22.4.14Uniquely identifies the procedure activity procedure sub-section.

Procedure Activity Procedure Code

component/section/entry/procedure/code

Provides information about the type of procedure presented in this sub-section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<code code="103716009" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Stent Placement"/>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure

code

codeMust be an alphanumeric string that represents the procedure activity from various coding systems (such as SNOMED CT or LOINC).

If no  code  attribute is present, a  nullFlavor  attribute MUST be present instead. Otherwise, the  code  element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be an alphanumeric string of any length in the following format: 2.16.840.1.113883.X.XXUnique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity procedure section.

Procedure Activity Procedure Status Code

component/section/entry/procedure/statusCode

Indicates the current status of the procedure.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<statusCode code="completed"/>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure

statusCode

code

Must be one of the following:

  • aborted
  • active
  • cancelled
  • completed
 

Procedure Activity Procedure Effective Time

component/section/entry/procedure/effectiveTime

Specifies the date and time the procedure occurred. Refer to How Effective Time values are processed for details on the different ways effectiveTime information can be processed.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<effectiveTime value="20110215"/>
			</procedure>
		</entry>
	</section>
</component>
...

Procedure Activity Procedure Priority Code

component/section/entry/Procedure/priorityCode

Specifies the priority placed on the procedure described within this sub-section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results"/>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure

priorityCode

codeMust be

an alphanumerical string of any length. For example, could be one of the following:

  • A - ASAP
  • CR - Callback results
  • EL - Elective
  • R - Routine

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be 2.16.840.1.113883.5.7Unique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity procedure priority code.

Procedure Activity Procedure Target Site Code

component/section/entry/procedure/targetSiteCode

Indicates the where on the patient's body the procedure was performed.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<targetSiteCode code="416949008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Abdomen and pelvis"/>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure
targetSiteCode
code

Must be one of the the Body Site codes specified by the SNOMED CT coding system.

For example:

  • 302539009 - Entire Hand
  • 28726007 - Corneal Structure
  • 3341006 - Right Lung Structure

 

codeSystem

Must be 2.16.840.1.113883.6.96

This is the unique identifier for the SNOMED CT coding system. It will be used to translate the value provided in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity procedure target site code.

Procedure Activity Procedure Author

component/section/entry/procedure/author

Specifies the author responsible for documenting the procedure activities for the particular section. Refer to Assigned Author Element for more details on what information can be available for the author section. 

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<author>
					<assignedAuthor>
						...
					</assignedAuthor>
				</author>
			</procedure>
		</entry>
	</section>
</component>
...

Procedure Activity Procedure Performer

component/section/entry/procedure/performer

Specifies the person performing the procedure. Refer to Performer Element for more details on what information can be available for the performer section. 

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
				<performer>
					<assignedEntity>
						...
					</assignedEntity>
				</performer>
			</procedure>
		</entry>
	</section>
</component>
...

Procedure Activity Procedure Indication

component/section/entry/procedure/entryRelationship

Specifies the rational for a procedure activity procedure section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				...
				<entryRelationship typeCode="RSON">
					...
				</entryRelationship>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity ProcedureentryRelationshiptypeCodeMust be RSON 

Procedure Activity Procedure Indication Observation Value

component/section/entry/procedure/entryRelationship/observation/value

Specifies the observed value for the rational for a procedure activity procedure section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				...
				<entryRelationship typeCode="RSON">
					<observation classCode="OBS" moodCode="EVN">
						<value xsi:type="CD" code="32398004" displayName="Bronchitis" codeSystem="2.16.840.1.113883.6.96" />
					</observation>
				</entryRelationship>
			</procedure>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Procedure

value

xsi:type

Must be CD

Indicates that the value element is providing code and codeSystem information

codeMust be an alphanumerical string of any length

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be 2.16.840.1.113883.6.96Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute.
displayNameCan be an alphanumeric string of any lengthThis attribute is optional. A human readable display name for the indication value.

Procedure Activity Procedure Encounter

component/section/entry/procedure/entryRelationship/encounter

Specifies any encounters in another section that relates to this procedure activity procedure section.

Information about this section and its children elements are detailed  in EncounterCCDA: Data Preparation Checklist.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<procedure classCode="PROC" moodCode="EVN">
				...
				<entryRelationship typeCode="COMP">
					<encounter classCode="ENC" moodCode="EVN">
						...
					</encounter>
				</entryRelationship>
			</procedure>
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Procedure Activity Procedure

entryRelationship

typeCodeMust be COMP 
  • entryRelationship
    • encounter
classCodeMust be ENCSpecifies the general nature of the entry, which in this case is an encounter (ENC).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing act, or was documented from a past act.

Procedure Activity Observation

component/section/entry/observation

This section describes procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 Reference Information Model (RIM). Examples of these procedures are diagnostic imaging procedures, EEGs, and EKGs.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				...
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

observation

classCodeMust be OBSSpecifies the general nature of the entry, which in this case is an observation (OBS).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing activity, or was documented from a past activity.

Procedure Activity Observation Template ID

component/section/entry/observation/templateId

Specifies which CCDA R2.1 template is being used to structure the procedure activity observation section. R2.1 templates define the requirements, format, and structure of a CCD section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

templateId

rootMust be 2.16.840.1.113883.10.20.22.4.13Uniquely identifies the procedure activity observation sub-section.

Procedure Activity Observation Code

component/section/entry/observation/code

Provides information about the type of observation presented in this sub-section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<code code="274025005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT" displayName="Colonic polypectomy"/>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

code

codeMust be an alphanumeric string that represents the procedure activity from various coding systems (such as SNOMED CT or LOINC).

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be an alphanumeric string of any length in the following format: 2.16.840.1.113883.X.XXUnique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity observation section.

Procedure Activity Observation Status Code

component/section/entry/observation/statusCode

Indicates the current status of the procedure described in this sub-section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<statusCode code="completed"/>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

statusCode

code

Must be one of the following:

  • aborted
  • active
  • cancelled
  • completed
 

Procedure Activity Observation Effective Time

component/section/entry/observation/effectiveTime

Specifies the start date, duration, and end date (if known) of the procedure. Refer to How Effective Time values are processed for details on the different ways effectiveTime information can be processed.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<effectiveTime xsi:type="IVL_TS">
					<low value="20110215"/>
					<high value="20180130"/>
				</effectiveTime>
			</observation>
		</entry>
	</section>
</component>
...

Procedure Activity Observation Priority Code

component/section/entry/observation/priorityCode

Specifies the priority placed on the procedure described within this sub-section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results"/>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

priorityCode

codeMust be

an alphanumerical string of any length. For example, could be one of the following:

  • A - ASAP
  • CR - Callback results
  • EL - Elective
  • R - Routine

 

codeSystemMust be 2.16.840.1.113883.5.7Unique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity observation priority code.

Procedure Activity Observation Value

component/section/entry/observation/value

Indicates the value of what was observed from the procedure activity.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<value xsi:type="CD" code="31712002" codeSystem="2.16.840.1.113883.6.96"/>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

value

xsi:typeMust be CD

Indicates this is a 'coded value' where the value element is providing code and codeSystem information.

code

Must be one of the the codes specified by the SNOMED CT coding system.

For example, 46635009 (Diabetes mellitus type 1) or 31712002 (Primary Biliary Cirrhosis).

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystem Must be 2.16.840.1.113883.6.96This is the unique identifier for the SNOMED CT coding system. It will be used to translate the value provided in the code attribute.

Procedure Activity Observation Target Site Code

component/section/entry/observation/targetSiteCode

Indicates the where on the patient's body the procedure was performed.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<targetSiteCode code="416949008" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Abdomen and pelvis"/>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation
targetSiteCode
code

Must be one of the the Body Site codes specified by the SNOMED CT coding system.

For example:

  • 302539009 - Entire Hand
  • 28726007 - Corneal Structure
  • 3341006 - Right Lung Structure

 

codeSystem

Must be 2.16.840.1.113883.6.96

This is the unique identifier for the SNOMED CT coding system. It will be used to translate the value provided in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity observation target site code.

Procedure Activity Observation Author

component/section/entry/observation/author

Indicates the person responsible for documenting the procedure activity observation sub-section. Refer to Assigned Author Element for more details on what information can be available for the author section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<author>
					<assignedAuthor>
						...
					</assignedAuthor>
				</author>
			</observation>
		</entry>
	</section>
</component>
...

Procedure Activity Observation Performer

component/section/entry/observation/performer

Indicates the person performing the procedure. Refer to Performer Element for more details on what information can be available for the performer section. 

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
				<performer>
					<assignedEntity>
						...
					</assignedEntity>
				</performer>
			</observation>
		</entry>
	</section>
</component>
...

Procedure Activity Observation Indication

component/section/entry/observation/entryRelationship

Specifies the rational for a procedure activity observation section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				...
				<entryRelationship typeCode="RSON">
					...
				</entryRelationship>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity ObservationentryRelationshiptypeCodeMust be RSON 

Procedure Activity Observation Indication Observation Value

component/section/entry/observation/entryRelationship/observation/value

Specifies the observed value for the rational for a procedure activity observation section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				...
				<entryRelationship typeCode="RSON">
					<observation classCode="OBS" moodCode="EVN">
						<value xsi:type="CD" code="32398004" displayName="Bronchitis" codeSystem="2.16.840.1.113883.6.96" />
					</observation>
				</entryRelationship>
			</observation>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Observation

value

xsi:type

Must be CD

Indicates that the value element is providing code and codeSystem information

codeMust be an alphanumerical string of any length

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be 2.16.840.1.113883.6.96Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute.
displayNameCan be an alphanumeric string of any lengthThis attribute is optional. A human readable display name for the indication value.

Procedure Activity Observation Encounter

component/section/entry/observation/entryRelationship/encounter

Specifies any encounters in another section that relates to this procedure activity observation section.

Information about this section and its children elements are detailed in EncounterCCDA: Data Preparation Checklist.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<observation classCode="OBS" moodCode="EVN">
				...
				<entryRelationship typeCode="COMP">
					<encounter classCode="ENC" moodCode="EVN">
						...
					</encounter>
				</entryRelationship>
			</observation>
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Procedure Activity Observation

entryRelationship

typeCodeMust be COMP 
  • entryRelationship
    • encounter
classCodeMust be ENCSpecifies the general nature of the entry, which in this case is an encounter (ENC).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing act, or was documented from a past act.

Procedure Activity Act

component/section/entry/act

This section represents any act that cannot be classified as an observation or procedure according to the HL7 RIM. Examples of these acts are a dressing change, teaching or feeding a patient, or providing comfort measures.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				...
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Act

act

classCodeMust be ACTSpecifies the general nature of the entry, which in this case is an act (ACT).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing activity, or was documented from a past activity.

Procedure Activity Act Template ID

component/section/entry/act/templateId

Specifies which CCDA R2.1 template is being used to structure the procedure activity act section. R2.1 templates define the requirements, format, and structure of a CCD section. 

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Act

templateId

rootMust be 2.16.840.1.113883.10.20.22.4.12Uniquely identifies the procedure activity act sub-section.

Procedure Activity Act Code

component/section/entry/act/code

Provides information about the type of procedure presented in this sub-section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
				<code code="274025005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Colonic polypectomy"/>
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Act

code

codeMust be an alphanumeric string that represents the procedure activity from various coding systems (such as SNOMED CT or LOINC).

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be an alphanumeric string of any length in the following format: 2.16.840.1.113883.X.XXUnique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity act section.

Procedure Activity Act Status Code

component/section/entry/act/code

Indicates the current status of the procedure activity act.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
				<statusCode code="cancelled"/>
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Act

statusCode

code

Must be one of the following:

  • aborted
  • active
  • cancelled
  • completed
 

Procedure Activity Act Effective Time

component/section/entry/act/effectiveTime

Specifies the date and time the procedure occurred. Refer to How Effective Time values are processed for details on the different ways effectiveTime information can be processed.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
				<effectiveTime xsi:type="IVL_TS">
					<low value="20110215"/>
					<high value="20180130"/>
				</effectiveTime>
			</act>
		</entry>
	</section>
</component>
...

Procedure Activity Act Priority Code

component/section/entry/act/priorityCode

Indicates the where on the patient's body the procedure was performed.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
				<priorityCode code="CR" codeSystem="2.16.840.1.113883.5.7" codeSystemName="ActPriority" displayName="Callback results"/>
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Act

priorityCode

codeMust be

an alphanumerical string of any length. For example, could be one of the following:

  • A - ASAP
  • CR - Callback results
  • EL - Elective
  • R - Routine

 

codeSystemMust be 2.16.840.1.113883.5.7Unique identifier for the Coding System that should be used to resolve the value specified in the code attribute.
codeSystemNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the code system.
displayNameCan be an alphanumerical string of any lengthThis attribute is optional. A human readable display name for the procedure activity act priority code.

Procedure Activity Act Author

component/section/entry/act/author

Indicates the person responsible for documenting the procedure activity act sub-section. Refer to Assigned Author Element for more details on what information can be available for the author section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
				<author>
					<assignedAuthor>
						...
					</assignedAuthor>
				</author>
			</act>
		</entry>
	</section>
</component>
...

Procedure Activity Act Performer

component/section/entry/act/performer

Indicates the person performing the procedure. Refer to Performer Element for more details on what information can be available for the performer section. 

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
				<performer>
					<assignedEntity>
						...
					</assignedEntity>
				</performer>
			</act>
		</entry>
	</section>
</component>
...

Procedure Activity Act Indication

component/section/entry/act/entryRelationship

Specifies the rational for a procedure activity act section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				...
				<entryRelationship typeCode="RSON">
					...
				</entryRelationship>
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity ActentryRelationshiptypeCodeMust be RSON 

Procedure Activity Act Indication Observation Value

component/section/entry/act/entryRelationship/observation/value

Specifies the observed value for the rational for a procedure activity act section.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				...
				<entryRelationship typeCode="RSON">
					<observation classCode="OBS" moodCode="EVN">
						<value xsi:type="CD" code="32398004" displayName="Bronchitis" codeSystem="2.16.840.1.113883.6.96" />
					</observation>
				</entryRelationship>
			</act>
		</entry>
	</section>
</component>
...
SubsectionElementAttributeValueNotes
Procedure Activity Act

value

xsi:type

Must be CD

Indicates that the value element is providing code and codeSystem information

codeMust be an alphanumerical string of any length

If no code attribute is present, a nullFlavor attribute MUST be present instead. Otherwise, the code element will not be processed. Refer to How nullFlavor Values are Processed in Coded Elements for details on nullFlavor attributes.

codeSystemMust be 2.16.840.1.113883.6.96Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute.
displayNameCan be an alphanumeric string of any lengthThis attribute is optional. A human readable display name for the indication value.

Procedure Activity Act Encounter

component/section/entry/act/entryRelationship/encounter

Specifies any encounters in another section that relates to this procedure activity act section.

Information about this section and its children elements are detailed in EncounterCCDA: Data Preparation Checklist.

...
<component>
    <section>
		...
		<entry typeCode="DRIV">
			<act classCode="ACT" moodCode="EVN">
				...
				<entryRelationship typeCode="COMP">
					<encounter classCode="ENC" moodCode="EVN">
						...
					</encounter>
				</entryRelationship>
			</act>
		</entry>
	</section>
</component>
...
SectionElementAttributeValueNotes
Procedure Activity Act

entryRelationship

typeCodeMust be COMP 
  • entryRelationship
    • encounter
classCodeMust be ENCSpecifies the general nature of the entry, which in this case is an encounter (ENC).
moodCodeMust be EVNIndicates that this entry is an event (EVN) that actually happens, has happened or is an ongoing act, or was documented from a past act.


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