Procedures Section Observation Entry

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Approval Status

  • Approval Status: Approved
  • Example Task Force: 5/22/2014

  • SDWG: 5/29/2014

  • SDWG C-CDA R2.1 Upgrade: 12/1/2016

C-CDA 2.1 Example:

  • 2.16.840.1.113883.10.20.22.2.7.1:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.13:2014-06-09
  • 2.16.840.1.113883.10.20.22.4.119

Reference to full CDA sample:

  • Procedure in empty CCD

Validation location

Comments

  • This example illustrates how an observation within a procedure section.

    Custodian

  • John D'Amore jdamore@diameterhealth.com (GitHub: jddamore)

Keywords

  • problems

Permalink

Links

 

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>Description</th>
					<th>Date and Time (Range)</th>
					<th>Status</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Procedure2">
					<td ID="ProcedureDesc2">Electrocardiogram (12-Lead)</td>
					<td>29 Mar 2014 09:15am</td>
					<td>Completed</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<!-- Observations should be used for care that result in information about the patient (e.g. a diagnostic test & result) but do not alter physical state-->
		<observation classCode="OBS" moodCode="EVN">
			<templateId root="2.16.840.1.113883.10.20.22.4.13"/>
			<templateId root="2.16.840.1.113883.10.20.22.4.13" extension="2014-06-09"/>
			<id root="c03e5445-af1b-4911-a419-e2782f21448c"/>
			<code code="268400002" codeSystem="2.16.840.1.113883.6.96" displayName="12 lead electrocardiogram" codeSystemName="SNOMED-CT">
				<originalText>
					<reference value="#ProcedureDesc2"/>
				</originalText>
				<translation code="93000" codeSystem="2.16.840.1.113883.6.12" displayName="Electrocardiogram, complete" codeSystemName="CPT" />
				<translation code="G8704" codeSystem="2.16.840.1.113883.6.13" displayName="12-Lead Electrocardiogram (Ecg) Performed" codeSystemName="HCPCS"/>
				<translation code="89.52" codeSystem="2.16.840.1.113883.6.104" displayName="Electrocardiogram" codeSystemName="ICD-9 Procedure"/>
				<translation code="4A02X4Z" codeSystem="2.16.840.1.113883.6.4" displayName="Measurement of Cardiac Electrical Activity, External Approach" codeSystemName="ICD-10 Procedure"/>
			</code>
			<text>
				<reference value="#Procedure2" />
			</text>
			<statusCode code="completed"/>
			<effectiveTime value="20140329091522-0500" />
			<!-- When choosing an observation, value records relevant findings-->
			<value xsi:type="CD" code="251135002" codeSystem="2.16.840.1.113883.6.96" displayName="Borderline normal electrocardiogram" codeSystemName="SNOMED-CT" />
		</observation>
	</entry>
</section>

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