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top
To accurately process the Header and Procedures sections of a C-CDA CCD, in the Clinical:ProceduresCcda ProcedureCcda Data Space, certain elements are required and must contain valid information. There are also certain elements that are optional but, if present, must also contain valid information. 

...

 Section or Sub-SectionElementXPath
Required ElementsProcedures SectiontemplateIdsection/templateId
codesection/code
Optional (but validated
if present) Elements
Procedure Activity ProceduretemplateIdsection/entry/procedure/templateId
codesection/entry/procedure/code
statusCodesection/entry/procedure/statusCode
effectiveTimesection/entry/procedure/effectiveTime
authorsection/entry/procedure/author
performersection/entry/procedure/performer
Procedure Activity Procedure (Indication)templateIdsection/entry/procedure/entryRelationship/observation/templateId
valuesection/entry/procedure/entryRelationship/observation/value
Procedure Activity ObservationtemplateIdsection/entry/observation/templateId
codesection/entry/observation/code
statusCodesection/entry/observation/statusCode
effectiveTimesection/entry/observation/effectiveTime
priorityCodesection/entry/observation/priorityCode
valuesection/entry/observation/value
targetSiteCodesection/entry/observation/targetSiteCode
authorsection/entry/observation/author
performersection/entry/observation/performer
Procedure Activity Observation (Indication)templateIdsection/entry/observation/entryRelationship/observation/templateId
valuesection/entry/observation/entryRelationship/observation/value
Procedure Activity ActtemplateIdsection/entry/act/templateId
codesection/entry/act/code
statusCodesection/entry/act/statusCode
effectiveTimesection/entry/act/effectiveTime
priorityCodesection/entry/act/priorityCode
authorsection/entry/act/author
performersection/entry/act/performer
Procedure Activity Act (Indication)templateIdsection/entry/act/entryRelationship/observation/templateId
valuesection/entry/act/entryRelationship/observation/value
Info

A full copy of the sample Continuity of Care Document (CCD) used in this section is attached.

 

...

Anchor
required
required
Required Elements

This section details the elements that are required for processing in Clinical Data Spaces, that is, they must be present, contain certain information, and be correct.

Anchor
pstemplate
pstemplate
Procedures Section templateId

XPath:section/templateID
Purpose:

Specifies which CCDA R2.1 template is being used to structure the procedures section. R2.1 templates define the requirements, format, and structure of a CCD section. This section describes all interventional, surgical, diagnostic, or therapeutic procedures or treatments relevant to the patient at the time the document is generated.

The templateID element must:

  • be present
  • contain a root attribute

    AttributeValuePurpose
    rootMust have a value of 2.16.840.1.113883.10.20.22.2.7Uniquely identifies the procedures section template
Code Block
languagexml
titleCode Example of Procedures Section templateId
collapsetrue
<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.7"/>
</section>
Warning

The entire procedures section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.2.7. The information provided in this section will not be processed and you will not receive any notification that this section was ignored.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

Anchor
pscode
pscode
Procedures Section code

XPath:section/code
Purpose:

Identifies that this section is detailing procedural information.

The code element must:

  • be present
  • contain code and codeSystem attributes

    AttributeValuePurpose

    code

    Must have a value of 47519-4

    Identifies that this section is detailing procedural information

    codeSystem

    Must have a value of 2.16.840.1.1113883.6.1

    Identifies the LOINC coding system used to translate the identifier provided in the code attribute
Code Block
languagexml
titleCode Example of Procedures Section code
collapsetrue
<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.7"/>
	<code code="47519-4" codeSystem "2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURES"/>
</section> 
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

...

Anchor
optional
optional
Optional Elements

This section details elements that are not required but if present, must contact certain information and be correct for accurate processing in Clinical Data Spaces (CDS). 

 

Anchor
paptemplate
paptemplate
Procedure Activity Procedure templateId

XPath:section/entry/procedure/templateId
Purpose:

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

If present, the templateId element must:

  • have a parent element of procedure with a classCode attribute of PROC and a moodCode attribute of EVN
  • contain a root attribute

    AttributeValuePurpose
    rootMust have a value of 2.16.840.1.113883.10.20.22.4.14Uniquely identifies the procedure activity procedure sub-section
Code Block
languagexml
titleCode Example of Procedure Activity Procedure templateId
collapsetrue
<entry typeCode="DRIV">
	<procedure classCode="PROC" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
	</procedure>
</entry>
 
Warning

The entire procedure activity procedure sub-section is ignored if the templateId element is not provided with a root value of 2.16.840.1.113883.10.20.22.4.14. You will not receive any notification that that this sub-section was ignored.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papcode
papcode
Procedure Activity Procedure code

XPath:section/entry/procedure/code
Purpose:

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

If present, the code element must:

contain code and codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumeric string of any length

Identifies the type of procedure presented in this sub-section

codeSystemMust include a numeric string of any length in the following format: 2.16.840.1.1113883.X.XXIdentifies the coding system used to translate the identifier provided in the code attribute

 

Note

displayName and codeSystemName are not required for processing

Note

For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <code nullFlavor="UNK"/>or <code nullFlavor="OTH"/> is acceptable.

If code is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Procedure Activity Procedure code
collapsetrue
<entry typeCode="DRIV">
	<procedure classCode="PROC" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
		<code code="274025005" codeSystem="2.16.840.1.113883.6.96" displayName="Colonic polypectomy">
	</procedure>
</entry> 
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papstatus
papstatus
Procedure Activity Procedure statusCode

XPath:section/entry/procedure/statusCode
Purpose:

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

If present, the statusCode element must:

contain a code attribute

AttributeValuePurpose
code

Must be one of the following:

  • aborted
  • active
  • cancelled
  • completed
Indicates the current status of the procedure
Code Block
languagexml
titleCode Example of Procedure Activity Procedure statusCode
collapsetrue
<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> 
Warning

Processing of the statusCode element will fail if it does not contain a correctly populated code attribute.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papeffective
papeffective
Procedure Activity Procedure effectiveTime

XPath:section/entry/procedure/effectiveTime
Purpose:

Indicates the time the procedure occurred.

If present, the effectiveTime element must:

Contain an attribute of xsi:typevalue OR nullFlavor

AttributeValuePurpose
xsi:type

Must be populated with IVL_TS and effectiveTime must:

  1. have a low child element, which can be:
    • empty
    • have a nullFlavor attribute
    • have a value attribute indicating a specific date and time
  2. optionally have a high child element which can be:
    • empty
    • have a nullFlavor attribute
    • have a value attribute indicating a specific date and time
Indicates the period over which the procedure occurred.
valueMust be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] where +/-ZZZZspecifies the offset from Coordinated Universal Time. Indicates the specific time the procedure occurred.
nullFlavor

Must be one of the following:

  • ASKU - asked but unknown
  • MSK - masked (for sensitivity or confidentiality reasons)
  • NA - not available, system down
  • NASK - not asked
  • NAV - not available
  • NI - no information
  • OTH - other
  • UNK - unknown
Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present. In this case, it suggests a procedure occurred, but it was not recorded when.
Code Block
languagexml
titleCode Example of Procedure Activity Procedure effectiveTime
collapsetrue
<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> 
Warning

Processing of the effectiveTime element will fail if it does not contain a correctly populated xsi:typevalue or nullFlavor attribute.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papauthor
papauthor
Procedure Activity Procedure author

XPath:section/entry/procedure/author
Purpose:

Indicates the unique identifier of the person responsible for documenting the procedure activity procedure sub-section

If present, the author element must:

  • have a child element of assignedAuthor, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose

    root

    Must include an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

    For example, OID: 2.16.840.1.1113883.x.xx.x  or  UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

    Uniquely identifies the author of the procedure activity procedure sub-section

    extensionIs optional and can include an alphanumeric string of any lengthUniquely identifies the author of the procedure activity procedure sub-section
Code Block
languagexml
titleProcedure Activity Procedure author
collapsetrue
<entry typeCode="DRIV">
	<procedure classCode="PROC" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
		<author>
			<assignedEntity>
				<id root=""20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
			</assignedEntity>
		</author>
	</procedure>
</entry> 
Warning

The author element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the author element in the document header will be processed instead.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papperformer
papperformer
Procedure Activity Procedure performer

XPath:section/entry/procedure/performer
Purpose:

Indicates the unique identifier of the person performing the procedure

If present, the performer element must:

  • have a child element of assignedEntity, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    rootMust include an alphanumeric string in the following OID (object identifier) format. It is not constrained by length: 2.16.840.1.1113883.x.xx.xUniquely identifies the performer of the procedure detailed in this sub-section

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the performer of the procedure detailed in this sub-section

Code Block
languagexml
titleCode Example of Procedure Activity Procedure performer
collapsetrue
<entry typeCode="DRIV">
	<procedure classCode="PROC" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
		<performer>
			<assignedEntity>
				<id root="c2ee9ee9-ae31-4628-a919-fec1cbb58687"/>
			</assignedEntity>
		</performer>
	</procedure>
</entry>  
Warning

The performer element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the performer element in the document header will be processed instead.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papitemplate
papitemplate
Procedure Activity Procedure (Indication) templateId

XPath:section/entry/procedure/entryRelationship/observation/templateId
Purpose:Specifies which CCDA R2.1 template is being used to structure the indication sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section describes the reason and/or rationale for the procedure.
If present, the templateId element must:
  • be contained within an entryRelationship element with a typeCode attribute of "RSON"
  • have a parent element of observation
  • contain a root attribute

    AttributeValuePurpose
    root2.16.840.1.113883.10.20.22.4.19Unique identifies the Procedure Activity Procedure (Indication) templateId
Code Block
languagexml
titleCode Example of Procedure Activity Procedure (Indication) templateId
collapsetrue
<entry typeCode="DRIV">
	<procedure classCode="PROC" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
		<entryRelationship typeCode="RSON">
			<observation>
				<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
			</observation>
		</entryRelationship>
	</procedure>
</entry>   
Warning

The entire procedure activity procedure (indication) sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113.883.10.20.22.4.19. The information provided in this sub-section will not be processed and you will not receive any notification that this sub-section was ignored.

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
papivalue
papivalue
Procedure Activity Procedure (Indication) value

XPath:section/entry/procedure/entryRelationship/observation/value
Purpose:

Indicates the specific reason and/or rationale for the procedure

If present, the value element must:

  • be contained within an entryRelationship element with a typeCode attribute of "RSON", which has a templateId of 2.16.840.1.113883.10.20.22.4.19
  • have a parent element of observation
  • contain xsi:type, code and codeSystem attributes

    AttributeValuePurpose
    xsi:typeMust have a value of CDIndicates that the value element is providing code and codeSystem information
    codeMust have an alphanumeric valueIdentifies the specific reason and/or rationale for the procedure
    codeSystem

    Must have a value of 2.16.840.1.113883.6.96

    Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute

    Note

    displayName and codeSystemName are not required for processing

    Note

    For accurate processing, we except to see value with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/>or <value nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

 

Code Block
languagexml
titleCode Example of Procedure Activity Procedure (Indication) value
collapsetrue
<entry typeCode="DRIV">
	<procedure classCode="PROC" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
		<entryRelationship typeCode="RSON">
			<observation>
				<templateId root="2.16.840.1.113883.10.20.22.4.19"/>
				<value xsi:type="CD" code="68496003" displayName="Polyp of colon" codeSystem="2.16.840.1.113883.6.96"/>
			</observation>
		</entryRelationship>
	</procedure>
</entry>   
Warning

Processing of the procedure/value element will fail if it does not contain correctly populated xsi:typecode, and codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paotemplate
paotemplate
Procedure Activity Observation templateId

XPath:section/entry/observation/templateId
Purpose:

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. This sub-section describes procedures that result in new information about a patient but do not cause physical alteration (for example, EEG).

If present, the templateId element must:

  • have a parent element of observation with a classCode attribute of OBS and a moodCode attribute of EVN
  • contain a root attribute

    AttributeValuePurpose
    rootMust have a value of 2.16.840.1.113883.10.20.22.4.13Uniquely identifies the procedure activity procedure sub-section
Code Block
languagexml
titleCode Example of Procedure Activity Observation templateId
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
	</observation>
</entry> 
Warning

The entire procedure activity observation sub-section is ignored if the templateId element is not provided with a root value of 2.16.840.1.113883.10.20.22.4.13. You will not receive any notification that that this sub-section was ignored.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paocode
paocode
Procedure Activity Observation code

XPath:section/entry/observation/code
Purpose:

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

If present, the code element must:

contain code and codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumeric string of any length

Identifies the type of procedure presented in this sub-section

codeSystemMust include a numeric string of any length in the following format: 2.16.840.1.1113883.X.XXIdentifies the coding system used to translate the identifier provided in the code attribute
Note

displayName and codeSystemName are not required for processing

Note

For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <code nullFlavor="UNK"/>or <code nullFlavor="OTH"/> is acceptable.

If code is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleProcedure Activity Observation code
collapsetrue
<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" displayName="Colonic polypectomy" codeSystemName="SNOMED-CT">
	</observation>
</entry>  
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paostatus
paostatus
Procedure Activity Observation statusCode

XPath:section/entry/observation/statusCode
Purpose:

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

If present, the statusCode element must:

contain a code attribute

AttributeValuePurpose
code

Must be one of the following:

  • aborted
  • active
  • cancelled
  • completed
Indicates the current status of the procedure
Code Block
languagexml
titleCode Example of Procedure Activity Observation statusCode
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<statusCode="completed"/>
	</observation>
</entry>  
Warning

Processing of the statusCode element will fail if it does not contain a correctly populated code attribute.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paoeffective
paoeffective
Procedure Activity Observation effectiveTime

XPath:section/entry/observation/effectiveTime
Purpose:

Indicates the time the procedure occurred.

If present, the effectiveTime element must:

Contain an attribute of xsi:typevalue OR nullFlavor

AttributeValuePurpose
xsi:type

Must be populated with IVL_TS and effectiveTime must:

  1. have a low child element, which can be:
    • empty
    • have a nullFlavor attribute
    • have a value attribute indicating a specific date and time
  2. optionally have a high child element which can be:
    • empty
    • have a nullFlavor attribute
    • have a value attribute indicating a specific date and time
Indicates the period over which the procedure occurred.
valueMust be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] where +/-ZZZZspecifies the offset from Coordinated Universal Time. Indicates the specific time the procedure occurred.
nullFlavor

Must be one of the following:

  • ASKU - asked but unknown
  • MSK - masked (for sensitivity or confidentiality reasons)
  • NA - not available, system down
  • NASK - not asked
  • NAV - not available
  • NI - no information
  • OTH - other
  • UNK - unknown
Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present. In this case, it suggests a procedure occurred, but it was not recorded when.
Code Block
languagexml
titleCode Example of Procedure Activity Observation effectiveTime
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<effectiveTime value="20110203"/>
	</observation>
</entry>   
Warning

Processing of the effectiveTime element will fail if it does not contain a correctly populated xsi:typevalue or nullFlavor attribute.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paopriority
paopriority
Procedure Activity Observation priorityCode

XPath:section/entry/observation/priorityCode
Purpose:

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

If present, the priorityCode element must:

Contain code and codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumerical string of any length. Could be one of the following:

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

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

codeSystemMust have a value of 2.16.840.1.1113883.5.7Identifies the coding system used to translate the identifier provided in the code attribute
Note

displayName and codeSystemName are not required for processing

Note

For accurate processing, we except to see priorityCode with code and codeSystem attributes, as documented above. However <priorityCode nullFlavor="UNK"/>or <priorityCode nullFlavor="OTH"/> is acceptable.

If priorityCode is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Procedure Activity Observation priorityCode
collapsetrue
<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>    
Warning

Processing of the priorityCode element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paovalue
paovalue
Procedure Activity Observation value

XPath:section/entry/observation/value
Purpose:

Indicates the rationale for this procedure

If present, the value element must:

  • have a parent element of observation
  • contain xsi:type, code and codeSystem attributes

    AttributeValuePurpose
    xsi:typeMust have a value of CDIndicates that the value element is providing code and codeSystem information
    codeMust have an alphanumeric valueIdentifies the specific reason and/or rationale for the procedure
    codeSystem

    Must have a value of 2.16.840.1.113883.6.96

    Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute

    Note

    displayName and codeSystemName are not required for processing

    Note

    For accurate processing, we except to see value with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/>or <value nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

 

Code Block
languagexml
titleCode Example of Procedure Activity
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<value xsi:type="CD""/>
	</observation>
</entry>    
Warning

Processing of the value element will fail if it does not contain correctly populated xsi:type, code, and codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

Anchor
paotarget
paotarget
Procedure Activity Observation targetSiteCode

XPath:section/entry/observation/targetSiteCode
Purpose:

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

If present, the targetSiteCode element must:

Contain code and codeSystem attributes

AttributeValuePurpose
code

Must have an alphanumeric value. Could be one of the following:

  • 302539009 - Entire Hand
  • 28726007 - Corneal Structure
  • 3341006 - Right Lung Structure
Identifies the area or specific body part on which the procedure was performed
codeSystem

Must have a value of 2.16.840.1.113883.6.96

Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute

Note

displayName and codeSystemName are not required for processing

Code Block
languagexml
titleCode Example of Procedure Activity Observation targetSiteCode
collapsetrue
<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>  
Warning

Processing of the targetSiteCode element will fail if it does not contain correctly populated code and codeSystem attributes.

 

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Anchor
paoauthor
paoauthor
Procedure Activity Observation author

XPath:section/entry/observation/author
Purpose:

Indicates the unique identifier of the person responsible for documenting the procedure activity observation sub-section

If present, the author element must:
  • have a child element of assignedAuthor, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose

    root

    Must include an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

    For example, OID: 2.16.840.1.1113883.x.xx.x  or  UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

    Uniquely identifies the author of the procedure activity observation sub-section

    extensionIs optional and can include an alphanumeric string of any lengthUniquely identifies the author of the procedure activity observation sub-section
Code Block
languagexml
titleCode Example of Procedure Activity Observation author
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<author>
            <assignedEntity>
                <id root="2.16.840.1.113883.19.5" extension"1234"/>
            </assignedEntity>
        </author>
	</observation>
</entry>  
Warning

The author element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the author element in the document header will be processed instead.

 

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Anchor
paoperformer
paoperformer
Procedure Activity Observation performer

XPath:section/entry/observation/performer
Purpose:

Indicates the unique identifier of the person performing the procedure

If present, the performer element must:

  • have a child element of assignedEntity, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    root

    Must include an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

    For example, OID: 2.16.840.1.1113883.x.xx.x  or  UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

    Uniquely identifies the performer of the procedure detailed in this sub-section
    extensionIs optional and can include an alphanumeric string of any lengthUniquely identifies the performer of the procedure detailed in this sub-section
Code Block
languagexml
titleCode Example of Procedure Activity Observation performer
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<performer>
            <assignedEntity>
                <id extension="56789" root="2.16.840.1.113883.19.5"/>
            </assignedEntity>
        </performer>
	</observation>
</entry>  
Warning

The performer element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the performer element in the document header will be processed instead.

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Anchor
paoitemplate
paoitemplate
Procedure Activity Observation (Indication) templateId

XPath:section/entry/observation/entryRelationship/observation/value
PurposeSpecifies which CCDA R2.1 template is being used to structure the indication sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section describes the reason and/or rational for the procedure.
If present, the value element must:
  • be contained within an entryRelationship element with a typeCode attribute of "RSON"
  • have a parent element of observation
  • contain a root attribute

    AttributeValuePurpose
    root2.16.840.1.113883.10.20.22.4.19Unique identifies the indication template 
Code Block
languagexml
titleCode Example of Procedure Activity Observation (Indication) templateId
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<entryRelationship typeCode="RSON">
            <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
            </observation>
        </entryRelationship>
	</observation>
</entry>   
Warning

The entire procedure activity observation (indication) sub-section is ignored if the templateId is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.19. The information provided in this sub-section will not be processed and you will not receive any notification that this sub-section was ignored.

 

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Anchor
paoivalue
paoivalue
Procedure Activity Observation (Indication) value

XPath:section/entry/observation/entryRelationship/observation/value
Purpose:

Indicates the rationale for this procedure

If present, the value element must:

  • be contained within an entryRelationship element with a typeCode attribute of "RSON", which has a templateId of 2.16.840.1.113883.10.20.22.4.19
  • have a parent element of observation
  • contain xsi:type, code and codeSystem attributes

    AttributeValuePurpose
    xsi:typeMust have a value of CDIndicates that the value element is providing code and codeSystem information
    codeMust have an alphanumeric valueIdentifies the specific reason and/or rationale for the procedure
    codeSystem

    Must have a value of 2.16.840.1.113883.6.96

    Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute

    Note

    displayName and codeSystemName are not required for processing

    Note

    For accurate processing, we except to see value with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/>or <value nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Procedure Activity Observation (Indication) value
collapsetrue
<entry typeCode="DRIV">
	<observation classCode="OBS" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
		<entryRelationship typeCode="RSON">
            <observation classCode="OBS" moodCode="EVN">
                <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
                <value xsi:type="CD" code="68496003" displayName="Polyp of colon" codeSystem="2.16.840.1.113883.6.96"/>
            </observation>
        </entryRelationship>
	</observation>
</entry>   
Warning

Processing of the observation/value element will fail if it does not contain correctly populated xsi:typecode, and codeSystem attributes.

 

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Anchor
paatemplate
paatemplate
Procedure Activity Act templateId

XPath:section/entry/act/templateId
Purpose:

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. This sub-section describes all other types of procedures that do fall within Procedure Activity Procedure (procedures that alter the physical condition of a patient) or Procedure Activity Observation (procedures that result in new information but do not cause physical alteration), for example a dressing change.

If present, the templateId element must:

  • have a parent element of act with a classCode attribute of ACT and a moodCode attribute of EVN
  • contain a root attribute

    AttributeValuePurpose
    rootMust have a value of 2.16.840.1.113883.10.20.22.4.12Uniquely identifies the procedure activity procedure sub-section
Code Block
languagexml
titleCode Example of Procedure Activity Act templateId
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
	</act>
</entry>  
Warning

The entire procedure activity act sub-section is ignored if the templateId element is not provided with a root value of 2.16.840.1.113883.10.20.22.4.12. You will not receive any notification that that this sub-section was ignored.

 

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Anchor
paacode
paacode
Procedure Activity Act code

XPath:section/entry/act/code
Purpose:

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

If present, the code element must:

contain code and codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumeric string of any length

Identifies the type of procedure presented in this sub-section

codeSystemMust include a numeric string of any length in the following format: 2.16.840.1.1113883.X.XXIdentifies the coding system used to translate the identifier provided in the code attribute
Note

displayName and codeSystemName are not required for processing

Note

For accurate processing, we except to see code with code and codeSystem attributes, as documented above. However <code nullFlavor="UNK"/>or <code nullFlavor="OTH"/> is acceptable.

If code is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Procedure Activity Act code
collapsetrue
<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>   
Warning

Processing of the code element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

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Anchor
paastatus
paastatus
Procedure Activity Act statusCode

XPath:section/entry/act/statusCode
Purpose:

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

If present, the statusCode element must:

contain a code attribute

AttributeValuePurpose
code

Must be one of the following:

  • aborted
  • active
  • cancelled
  • completed
Indicates the current status of the procedure
Code Block
languagexml
titleCode Example of Procedure Activity Act statusCode
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
		<statusCode code="completed"/>
	</act>
</entry>  
Warning

Processing of the statusCode element will fail if it does not contain a correctly populated code attribute.

 

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Anchor
paaeffective
paaeffective
Procedure Activity Act effectiveTime

XPath:section/entry/act/effectiveTime
Purpose:

Indicates the time the procedure occurred

If present, the effectiveTime element must:

Contain an attribute of xsi:typevalue OR nullFlavor

AttributeValuePurpose
xsi:type

Must be populated with IVL_TS and effectiveTime must:

  1. have a low child element, which can be:
    • empty
    • have a nullFlavor attribute
    • have a value attribute indicating a specific date and time
  2. optionally have a high child element which can be:
    • empty
    • have a nullFlavor attribute
    • have a value attribute indicating a specific date and time
Indicates the period over which the procedure occurred.
valueMust be populated with a date in the format YYYY[MM[DD[HHMM[SS[.S[S[S[S]]]]]]]][+/-ZZZZ] where +/-ZZZZspecifies the offset from Coordinated Universal Time. Indicates the specific time the procedure occurred.
nullFlavor

Must be one of the following:

  • ASKU - asked but unknown
  • MSK - masked (for sensitivity or confidentiality reasons)
  • NA - not available, system down
  • NASK - not asked
  • NAV - not available
  • NI - no information
  • OTH - other
  • UNK - unknown
Indicates that an attribute was required, but was not provided, and gives a reason for why the information is not present. In this case, it suggests a procedure occurred, but it was not recorded when.
Code Block
languagexml
titleCode Example of Procedure Activity Act effectiveTime
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
		<effectiveTime value="20110203"/>
	</act>
</entry>  
Warning

Processing of the effectiveTime element will fail if it does not contain a correctly populated xsi:typevalue or nullFlavor attribute.

 

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Anchor
paapriority
paapriority
Procedure Activity Act priorityCode

XPath:section/entry/act/priorityCode
Purpose:

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

If present, the priorityCode element must:

Contain code and codeSystem attributes

AttributeValuePurpose

code

Must include an alphanumerical string of any length. Could be one of the following:

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

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

codeSystemMust have a value of 2.16.840.1.1113883.5.7Identifies the coding system used to translate the identifier provided in the code attribute
Note

displayName and codeSystemName are not required for processing

Note

For accurate processing, we except to see priorityCode with code and codeSystem attributes, as documented above. However <priorityCode nullFlavor="UNK"/>or <priorityCode nullFlavor="OTH"/> is acceptable.

If priorityCode is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Procedure Activity Act priorityCode
collapsetrue
<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>   
Warning

Processing of the priorityCode element will fail if it does not contain correctly populated code AND codeSystem attributes.

 

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Anchor
paaauthor
paaauthor
Procedure Activity Act author

XPath:section/entry/act/author
Purpose:

Indicates the unique identifier of the person responsible for documenting the procedure activity act sub-section

If present, the author element must:
  • have a child element of assignedAuthor, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose

    root

    Must include an alphanumeric string in an OID (object identifier) or UUID (universally unique identifier) format. 

    For example, OID: 2.16.840.1.1113883.x.xx.x  or  UUID: 53459040-b1b4-49ed-ae1f-a52c8c502df4

    Uniquely identifies the author of the procedure activity procedure sub-section

    extensionIs optional and can include an alphanumeric string of any lengthUniquely identifies the author of the procedure activity procedure sub-section
Code Block
languagexml
titleCode Example of Procedure Activity Act author
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
		 <author>
            <assignedEntity>
                <id root="20cf14fb-b65c-4c8c-a54d-b0cca834c18c"/>
            </assignedEntity>
        </author>
	</act>
</entry>    
Warning

The author element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the author element in the document header will be processed instead.

 

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Anchor
paaperformer
paaperformer
Procedure Activity Act performer

XPath:section/entry/act/performer
Purpose:

Indicates the unique identifier of the person performing the procedure

If present, the performer element must:
  • have a child element of assignedEntity, which must
  • have a child element of id, which must
  • contain a root attribute and optionally contain an extension attribute

    AttributeValuePurpose
    rootMust include an alphanumeric string in the following OID (object identifier) format. It is not constrained by length: 2.16.840.1.1113883.x.xx.xUniquely identifies the performer of the procedure detailed in this sub-section

    extension

    Is optional and can include an alphanumeric string of any length

    Uniquely identifies the performer of the procedure detailed in this sub-section

Code Block
languagexml
titleCode Example of Procedure Activity Act performer
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<templateId root="2.16.840.1.113883.10.20.22.4.12"/>
        <performer>
            <assignedEntity>
                <id extension="56789" root="2.16.840.1.113883.19.5"/>
            </assignedEntity>
        </performer>
	</act>
</entry>     
Warning

The performer element and its contents will be ignored if the id element does not contain a correctly populated root attribute. Information provided within the performer element in the document header will be processed instead.

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Anchor
paaitemplate
paaitemplate
Procedure Activity Act (Indication) templateId

XPath:section/entry/actn/entryRelationship/observation/value
PurposeSpecifies which CCDA R2.1 template is being used to structure the indication sub-section. R2.1 templates define the requirements, format, and structure of a CCD section. This sub-section describes the reason and/or rationale for the procedure.
If present, the value element must:
  • be contained within an entryRelationship element with a typeCode attribute of "RSON"
  • have a parent element of observation
  • contain a root attribute

    AttributeValuePurpose
    root
    2.16.840.1.113883.10.20.22.4.19
    Unique identifies the indication template.
Code Block
languagexml
titleCode Example of Procedure Activity Act (Indication) templateId
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<entryRelationship typeCode="RSON">
            <observation>
                <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
            </observation>
        </entryRelationship>
	</act>
</entry>     
Warning

The entire procedure activity act (indication) sub-section is ignored if the templateId element is not provided with a root attribute of 2.16.840.1.113883.10.20.22.4.19. The information provided in this sub-section will not be processed and you will not receive any notification that this sub-section was ignored.

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Anchor
paaivalue
paaivalue
Procedure Activity Act (Indication) value

XPath:section/entry/act/entryRelationship/observation/value
Purpose:

Indicates the rationale for the procedure

If present, the value element must:

  • be contained within an entryRelationship element with a typeCode attribute of "SUBJ", which has a templateId of 2.16.840.1.113883.10.20.22.4.19
  • have a parent element of observation
  • contain xsi:type, code and codeSystem attributes

    AttributeValuePurpose
    xsi:typeMust have a value of CDIndicates that the value element is providing code and codeSystem information
    codeMust have an alphanumeric valueIdentifies the specific reason and/or rationale for the procedure
    codeSystem

    Must have a value of 2.16.840.1.113883.6.96

    Identifies the SNOMED CT coding system used to translate the identifier provided in the code attribute

    Note

    displayName and codeSystemName are not required for processing

    Note

    For accurate processing, we except to see value with code and codeSystem attributes, as documented above. However <value nullFlavor="UNK"/>or <value nullFlavor="OTH"/> is acceptable.

    If value is populated with nullFlavor="OTH", a child element of translation must be present and contain code and codeSystem attributes. Clinical Data Spaces will process the information provided here instead.

Code Block
languagexml
titleCode Example of Procedure Activity Act (Indication) value
collapsetrue
<entry typeCode="DRIV">
	<act classCode="ACT" moodCode="EVN">
		<entryRelationship typeCode="RSON">
            <observation>
                <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
                <value xsi:type="CD" code="32398004" displayName="Bronchitis" codeSystem="2.16.840.1.113883.6.96"/>
            </observation>
        </entryRelationship>
	</act>
</entry>     
Warning

Processing of the act/value element will fail if it does not contain correctly populated xsi:typecode, and codeSystem attributes.

 

ProceduresCCDA: Data Preparation ChecklistImage Added

 

ProceduresCCDA: Data Preparation ChecklistImage Added

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