ProcedureNote

Procedure Note

activeC-CDA on FHIR1.2.0resource130 key elements

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.

Metadata

hl7.org/fhir

Canonical URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Procedure-Note
ID: Procedure-Note
Type
Base Definition: US-Realm-Header
Derivation: constraint

Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

Path	Card.	Type	Flags	Description
type			S	Procedure Note
event			S1+	serviceEvent
event.period			1+	period
event.period.start			1+	start
event.period.end			1+	end
:complications_section	1..1		S1+	Complications Section
section.title			S1+	title
section.code			S1+	Complications
section.text			S1+	text
:complications_entry		Reference	S
:procedure_description_section	1..1		S1+	Procedure Description Section
section.title			S1+	title
section.code			S1+	Procedure description
section.text			S1+	This section contains only human readable content
:procedure_indications_section	1..1		S1+	Procedure Indications Section
section.title			S1+	title
section.code			S1+	Procedure indications
section.text			S1+	This section contains only human readable content
:postprocedure_diagnosis_section	1..1		S1+	Postprocedure Diagnosis Section
section.title			S1+	title
section.code			S1+	Postprocedure diagnosis
section.text			S1+	text
section.entry			S	entry
:postprocedure_diagnosis_entry		Reference	S
:allergies_and_intolerances_section			S	Allergies and Intolerances Section
section.title			S1+	title
section.code			S1+	Allergies and/or adverse reactions
section.text			S1+	text
:allergies_and_intolerances_entry		Reference	S
:assessment_section			S	Assessment Section
section.title			S1+	title
section.code			S1+	Assessments
section.text			S1+	This section contains only human readable content
:assessment_and_plan_section			S	Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements.
section.title			S1+	title
section.code			S1+	Assessment and plan
section.text			S1+	text
:assessment_and_plan_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:anesthesia_section			S	Anesthesia Section
section.title			S1+	title
section.code			S1+	Anesthesia
section.text			S1+	text
:anesthesia_entry		Reference	S
:chief_complaint_and_reason_for_visit_section			S	Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes.
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:chief_complaint_section			S	Chief Complaint Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:family_history_section			S	Family History Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:family_history_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:past_medical_history_section			S	Past Medical History Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	text
:past_medical_history_entry		Reference	S
:history_of_present_illness_section			S	History of Present Illness Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:medical_history_section			S	Medical (General) History Section
section.title			S1+	title
section.code			S1+	Medical (general) history
section.text			S1+	This section contains only human readable content
:medications_section			S	Medications Section
section.title			S1+	title
section.code			S1+	History of medication use
section.text			S1+	text
:medications_entry		Reference	S
:medications_administered_section			S	Medications Administered Section
section.title			S1+	title
section.code			S1+	Medications administered
section.text			S1+	text
:medications_administered_entry		Reference	S
:physical_exam_section			S	Physical Exam Section
section.title			S1+	title
section.code			S1+	Physical findings
section.text			S1+	text
:physical_exam_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:plan_of_treatment_section			S	Plan of Treatment Section
section.title			S1+	title
section.code			S1+	Plan of treatment
section.text			S1+	text
:planned_procedure_section			S	Planned Procedure Section
section.title			S1+	title
section.code			S1+	Planned procedure
section.text			S1+	text
:procedure_disposition_section			S	Procedure Disposition Section
section.title			S1+	title
section.code			S1+	Procedure disposition
section.text			S1+	This section contains only human readable content
:procedure_estimated_blood_loss_section			S	Procedure Estimated Blood Loss Section
section.title			S1+	title
section.code			S1+	Procedure estimated blood loss
section.text			S1+	This section contains only human readable content
:procedure_findings_section			S	Procedure Findings Section
section.title			S1+	title
section.code			S1+	Procedure findings
section.text			S1+	This section contains only human readable content
:procedure_implants_section			S	Procedure Implants Section
section.title			S1+	title
section.code			S1+	Procedure implants
section.text			S1+	This section contains only human readable content
:procedure_specimens_taken_section			S	Procedure Specimens Taken Section
section.title			S1+	title
section.code			S1+	Procedure specimens taken
section.text			S1+	This section contains only human readable content
:procedures_section			S	Procedures Section
section.title			S1+	title
section.code			S1+	History of procedures
section.text			S1+	text
:procedures_entry		Reference	S
:reason_for_visit_section			S	Reason for Visit Section
section.title			S1+	title
section.code			S1+	code
section.text			S1+	This section contains only human readable content
:review_of_systems_section			S	Review of Systems Section
section.title			S1+	title
section.code			S1+	Review of systems
section.text			S1+	This section contains only human readable content
:social_history_section			S	Social History Section
section.title			S1+	title
section.code			S1+	Social history
section.text			S1+	text
:social_history_entry		Reference	S	Smoking status