Procedure Note
A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.
The Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care.
Profile Name
ProcedureNote
Base Definition
Derivation
constraint
Differential Elements (145)
Constraints and modifications from the base definition
| Path | Cardinality | Type(s) | Must Support | Details |
|---|---|---|---|---|
Composition | - | - | - | - |
Composition.type | - | - | Yes | - |
Composition.event | 1..* | - | Yes | - |
Composition.event.period | 1..* | - | - | - |
Composition.event.period.start | 1..* | - | - | - |
Composition.event.period.end | 1..* | - | - | - |
Composition.section | - | - | - | - |
Composition.sectionSlice: complications_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: complications_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: procedure_description_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedure_indications_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: postprocedure_diagnosis_section | 1..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | Yes | - |
Composition.section.entrySlice: postprocedure_diagnosis_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: allergies_and_intolerances_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: allergies_and_intolerances_entry | - | Reference | Yes | Target: us-core-allergyintolerance |
Composition.sectionSlice: assessment_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: assessment_and_plan_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: assessment_and_plan_entry | - | Reference | Yes | Target: us-core-conditionObservationCommunication |
Composition.sectionSlice: anesthesia_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: anesthesia_entry | - | Reference | Yes | Target: MedicationStatementus-core-medicationus-core-medicationrequestus-core-procedure |
Composition.sectionSlice: chief_complaint_and_reason_for_visit_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: chief_complaint_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: family_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: family_history_entry | - | Reference | Yes | Target: FamilyMemberHistory |
Composition.sectionSlice: past_medical_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: past_medical_history_entry | - | Reference | Yes | Target: us-core-condition |
Composition.sectionSlice: history_of_present_illness_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: medical_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: medications_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: medications_entry | - | Reference | Yes | Target: MedicationStatementus-core-medicationus-core-medicationrequest |
Composition.sectionSlice: medications_administered_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: medications_administered_entry | - | Reference | Yes | Target: MedicationStatementus-core-medicationus-core-medicationrequest |
Composition.sectionSlice: physical_exam_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: physical_exam_entry | - | Reference | Yes | Target: Observation |
Composition.sectionSlice: plan_of_treatment_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: sliceEntry | - | Reference | - | Target: us-core-goalus-core-medicationrequestus-core-encounterCommunicationAppointmentCommunicationRequestDeviceRequestNutritionOrderTaskServiceRequestVisionPrescriptionRequestGroup |
Composition.sectionSlice: planned_procedure_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedure_disposition_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedure_estimated_blood_loss_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedure_findings_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedure_implants_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedure_specimens_taken_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: procedures_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: procedures_entry | - | Reference | Yes | Target: us-core-procedure |
Composition.sectionSlice: reason_for_visit_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: review_of_systems_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.sectionSlice: social_history_section | *..1 | - | Yes | - |
Composition.section.title | 1..* | - | Yes | - |
Composition.section.code | 1..* | - | Yes | - |
Composition.section.text | 1..* | - | Yes | - |
Composition.section.entry | - | - | - | - |
Composition.section.entrySlice: social_history_entry | - | Reference | Yes | Target: us-core-smokingstatus |