Procedure Unsuccessful

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 5/5/2022
  • SDWG: 3/9/2023

Templates

  • Procedure Section: 2.16.840.1.113883.10.20.22.2.7.1:2014-06-09
  • Procedure Actitivy Procedure: 2.16.840.1.113883.10.20.22.4.14:2014-06-09

Validation location:

  • TBD - Reference to full CDA sample: N/A

Comments

  • This is an example of an unsuccessful procedure attempt.

Custodian

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

Keywords

  • procedure, unsuccessful

Permalink

  • TBD

 

Example: download example view on GitHub 

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.7.1"/>
	<templateId root="2.16.840.1.113883.10.20.22.2.7.1" extension="2014-06-09"/>
	<code code="47519-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
		displayName="HISTORY OF PROCEDURES"/>
	<title>Procedures</title>
	<text>
		<table>
			<thead>
				<tr>
					<th>Procedure</th>
					<th>Date and Time (Range)</th>
					<th>Comment</th>
					<th>Reason</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Procedure1">
					<td ID="ProcedureDesc1">Chest X-ray</td>
					<td>03/31/2022 04:49 PM CST</td>
					<td ID="Procedure_0_comment">Unsuccessful</td>
					<td ID="Procedure_0_reason">Image unreadable</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry>
		<procedure moodCode="EVN" classCode="PROC">
			<templateId root="2.16.840.1.113883.10.20.22.4.14"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.14" extension="2014-06-09"/>
			<id root="9037af8a-b28f-4bb5-8a02-ff6ea1f24cb0"/>
			<code code="168731009" displayName="Standard chest X-ray"
				codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED-CT">
				<originalText>
					<reference value="#ProcedureDesc1"/>
				</originalText>
			</code>
			<text>
				<reference value="#Procedure1"/>
			</text>
			<!-- statusCode is completed because the procedure is complete, even though it was unsuccessful -->
			<statusCode code="completed"/>
			<!-- Effective times can be either a value or interval. For procedures with start and stop times, an interval would be more appropriate -->
			<effectiveTime value="20220331164901-0500"/>
			<entryRelationship typeCode="SUBJ" inversionInd="true">
				<act classCode="ACT" moodCode="EVN">
					<!-- No templateId currently exists for this...
                 		 One may be created in a future version of the C-CDA Companion Guide. -->
					<!-- REQUIRED: This code is the most important part of the act... it's really the
                		 only core requirement for marking the procedure as unsuccessful. -->
					<code code="103709008" codeSystem="2.16.840.1.113883.6.96"
						displayName="Failed attempted procedure"/>
					<!-- OPTIONAL: May contain info about why the procedure was unsuccessful -->
					<text>
						<reference value="#Procedure_0_reason" />
					</text>
					<!-- This statusCode is always "completed" since it refers to the action of having
						 documented that the procedure was unsuccessful. -->
					<statusCode code="completed"/>
					<!-- OPTIONAL: Instant the procedure was marked as unsuccessful -->
					<effectiveTime value="20220331165432-0500"/>
					<!-- OPTIONAL: Author who marked the procedure as unsuccessful -->
					<author>
						<templateId root="2.16.840.1.113883.10.20.22.4.119"/>
						<time value="20220331165432-0500"/>
						<assignedAuthor>
							<id extension="99999999" root="2.16.840.1.113883.4.6"/>
							<code code="207Q00000X" codeSystem="2.16.840.1.113883.6.101"
								codeSystemName="Health Care Provider Taxonomy"
								displayName="Allopathic &amp; Osteopathic Physicians; Family Medicine"/>
							<telecom use="WP" value="tel:555-555-1002"/>
							<assignedPerson>
								<name>
									<given>Henry</given>
									<family>Seven</family>
								</name>
							</assignedPerson>
						</assignedAuthor>
					</author>
				</act>
			</entryRelationship>
		</procedure>
	</entry>
</section>

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