Procedure Alternatives

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 7/14/2022
  • SDWG: 3/9/2023

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.4.41:2014-06-09

Validation location

Comments

  • This example illustrates a planned surgical procedure with multiple proposed alternatives, with the expectation that the surgeon will choose one to perform when the surgery actually occurs.

    Custodian

  • Matt Szczepankiewicz mszczepa@epic.com (GitHub: mjszczep)

Keywords

  • plan of treatment
  • procedure
  • alternative

Permalink

  • TBD

Links

 

Example: download example view on GitHub 

<section>
    <templateId root="2.16.840.1.113883.10.20.22.2.10"/>
    <templateId root="2.16.840.1.113883.10.20.22.2.10" extension="2014-06-09"/>
    <code code="18776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
        displayName="Plan of care note"/>
    <title>Plan of Treatment</title>
    <text>
        <table>
            <caption>Scheduled Procedures</caption>
            <colgroup>
                <col width="40%"/>
                <col width="10%"/>
                <col width="25%" span="2"/>
            </colgroup>
            <thead>
                <tr>
                    <th>Name</th>
                    <th>Priority</th>
                    <th>Associated Diagnoses</th>
                    <th>Date/Time</th>
                </tr>
            </thead>
            <tbody>
                <tr ID="procedure32">
                    <td>
                        <content ID="procedure32name">Appendectomy Open</content>
                    </td>
                    <td>Urgent</td>
                    <td>
                        <paragraph>Appendicitis</paragraph>
                    </td>
                    <td>04/30/2022 9:00 PM CDT</td>
                </tr>
            </tbody>
        </table>
    </text>
    <entry>
        <!-- Planned Procedure (V2) -->
        <procedure classCode="PROC" moodCode="INT">
            <templateId root="2.16.840.1.113883.10.20.22.4.41"/>
            <templateId root="2.16.840.1.113883.10.20.22.4.41" extension="2014-06-09"/>
            <id extension="237181-1-1" root="1.2.840.114350.1.13.861.1.7.1.1988.2"/>
            <code code="44950" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4"
                displayName="Appendectomy">
                <originalText>Appendectomy Open<reference value="#procedure32name"/></originalText>
                <translation code="80146002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
                    displayName="Excision of appendix"/>
            </code>
            <text>
                <reference value="#procedure32"/>
            </text>
            <statusCode code="active"/>
            <effectiveTime>
                <low value="20220430210000-0500"/>
                <high value="20220430213200-0500"/>
            </effectiveTime>
            <!-- Omitted: MAY contain zero or more [0..*] performer (CONF:1098-30449) -->
            <!-- Omitted: SHOULD contain zero or one [0..1] Author Participation (CONF:1098-31979) -->
            <!-- Priority Preference -->
            <entryRelationship typeCode="REFR">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.143"/>
                    <id nullFlavor="NI"/>
                    <code code="225773000" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
                        displayName="Preference"/>
                    <effectiveTime value="20220430201102-0500"/>
                    <value code="394849002" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
                        displayName="High priority" xsi:type="CD"
                        xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"/>
                </observation>
            </entryRelationship>
            <!-- Indication -->
            <entryRelationship typeCode="RSON">
                <observation classCode="OBS" moodCode="EVN">
                    <templateId root="2.16.840.1.113883.10.20.22.4.19"/>
                    <templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
                    <id extension="86579" root="1.2.840.114350.1.13.861.1.7.2.696871"/>
                    <code code="55607006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
                        displayName="Problem"/>
                    <text>Appendicitis</text>
                    <statusCode code="completed"/>
                    <value code="74400008" displayName="Appendicitis" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT"
                        xsi:type="CD" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
                        <translation code="K37" codeSystem="2.16.840.1.113883.6.90" codeSystemName="ICD10"/>
                        <translation code="541" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD9"/>
                    </value>
                </observation>
            </entryRelationship>
            <!-- Omitted: MAY contain zero or more [0..*] entryRelationship (CONF:1098-31985) such that it
                        SHALL contain exactly one [1..1] Instruction (V2) (CONF:1098-31989). -->
            <!-- Omitted: MAY contain zero or more [0..*] entryRelationship (CONF:1098-31990) such that it
                        SHALL contain exactly one [1..1] Planned Coverage (CONF:1098-31992). -->
            
            <!-- This entryRelationship contains an organizer listing alternative planned procedures...
                 The options below should be read as: CPT 44960 OR 44970 -->
            <entryRelationship typeCode="REFR">
                <organizer classCode="CLUSTER" moodCode="PRP">
                    <!-- "PRP" = proposal
                         A non-mandated intent to perform an act. Used to record intents that are explicitly not Orders.
                         Professional responsibility for the 'proposal' may or may not be present. -->
                    <!-- Implementers may include an organizer/code here with a value "alternative procedure options,"
                         although we were unable to find an appropriate one.  -->
                    
                    <statusCode code="active" />
                    
                    <!-- First alternative -->
                    <component>
                        <procedure classCode="SUBST" moodCode="PRP">
                            <!-- "SUBST" = substitution
                                 Indicates that the subject Act has undergone or should undergo substitution of a type indicated by Act.code. -->
                            <code code="44960" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4"
                                displayName="Appendectomy; for ruptured appendix with abscess or generalized peritonitis" />
                        </procedure>
                    </component>
                    
                    <!-- Second alternative -->
                    <component>
                        <procedure classCode="SUBST" moodCode="PRP">
                            <code code="44970" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4"
                                displayName="Laparoscopy, surgical, appendectomy" />
                        </procedure>
                    </component>
                    <!-- To represent multiple combined procedures as one option, an organizer may be used to group multiple proposed procedures -->
                </organizer>
            </entryRelationship>
        </procedure>
    </entry>
</section>

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