Procedures Section (entries required) (V2)

OID: 2.16.840.1.113883.10.20.22.2.7.1

LOINCs: #{"47519-4"}

Alias: procedures

Entries Required: true

Internal ID: ProceduresSectionentriesrequiredV

IG Link

Procedure example.

This is a typical procedure resource sample.

:performed field contains information about start and end dates of procedure.

:bodySite field contains information about body site of procedure.

:status field contains information about status of procedure.

In this case it is used to distinguish procedure from other acts like observation or even any act in common.

json

{
  "extension" : [ {
    "url" : "rim-class",
    "value" : {
      "code" : "procedure"
    }
  } ],
  "id" : "64af26d5-88ef-4169-ba16-c6ef16a1824f",
  "code" : {
    "coding" : [ {
      "code" : "6025007",
      "display" : "Laparoscopic appendectomy",
      "system" : "http://snomed.info/sct"
    }, {
      "code" : "44970",
      "display" : "Laparoscopic Appendectomy",
      "system" : "http://www.ama-assn.org/go/cpt"
    }, {
      "code" : "0DTJ4ZZ",
      "display" : "Resection of Appendix, Percutaneous Endoscopic Approach",
      "system" : "urn:oid:2.16.840.1.113883.6.4"
    }, {
      "code" : "47.01",
      "display" : "Laparoscopic appendectomy",
      "system" : "http://hl7.org/fhir/sid/icd-9-cm"
    } ]
  },
  "performed" : {
    "Period" : {
      "start" : "2014-02-03T09:22:05-07:00",
      "end" : "2014-02-03T11:15:14-07:00"
    }
  },
  "status" : "completed",
  "bodySite" : [ {
    "coding" : [ {
      "code" : "181255000",
      "display" : "Entire Appendix",
      "system" : "http://snomed.info/sct"
    } ]
  } ],
  "resourceType" : "Procedure",
  "subject" : {
    "id" : "patient",
    "resourceType" : "Patient"
  }
}

C-CDA Equivalent: ``xml

                Procedures Section (entries required) (V2)                                                  Procedures                 Date                 Status              
          
                                       Laparoscopic appendectomy                 02/03/2014 4:22PM UTC - 02/03/2014 6:15PM UTC                 completed

Procedures	Date	Status
Laparoscopic appendectomy	02/03/2014 4:22PM UTC - 02/03/2014 6:15PM UTC	completed

 `` 
Procedure Act example.
Th converter rules don't use :extension field to distinguish Procedure Act from other acts, but you can add related rules to do it.           
In this case :extension field is used to distinguish more common procedure act like patient education. 
json{
  "extension" : [ {
    "url" : "rim-class",
    "value" : {
      "code" : "act"
    }
  } ],
  "id" : "9c0f070c-2e9e-4be1-a5b5-ff6d0f68123c",
  "code" : {
    "coding" : [ {
      "code" : "61310001",
      "display" : "Nutrition education",
      "system" : "http://snomed.info/sct"
    }, {
      "code" : "97802",
      "display" : "Medical nutrition therapy; initial",
      "system" : "http://www.ama-assn.org/go/cpt"
    }, {
      "code" : "S9470",
      "display" : "Nutritional counseling, diet",
      "system" : "urn:oid:2.16.840.1.113883.6.13"
    }, {
      "code" : "V65.3",
      "display" : "Dietary surveillance and counseling",
      "system" : "urn:oid:2.16.840.1.113883.6.103"
    }, {
      "code" : "Z71.3",
      "display" : "Dietary counseling and surveillance",
      "system" : "http://hl7.org/fhir/sid/icd-10"
    } ]
  },
  "performed" : {
    "dateTime" : "2014-03-29T10:45:13-05:00"
  },
  "status" : "completed",
  "resourceType" : "Procedure",
  "subject" : {
    "id" : "patient",
    "resourceType" : "Patient"
  }
}
The section contains an Act entry converted from the input Procedure resource. ``xml 
                Procedures Section (entries required) (V2)                                                  Procedures                 Date                 Status              
          
                                       Nutrition education                 03/29/2014 3:45PM UTC                 completed              
          
       
                                                                                                                                                     
 `` 
Procedure Observation example.
Like the previous examples, this is a typical Procedure resource sample. 
json{
  "extension" : [ {
    "url" : "rim-class",
    "value" : {
      "code" : "observation"
    }
  } ],
  "id" : "c03e5445-af1b-4911-a419-e2782f21448c",
  "code" : {
    "coding" : [ {
      "code" : "268400002",
      "display" : "12 lead ECG",
      "system" : "http://snomed.info/sct"
    }, {
      "code" : "93000",
      "display" : "Electrocardiogram, complete",
      "system" : "http://www.ama-assn.org/go/cpt"
    }, {
      "code" : "G8704",
      "display" : "12-Lead Electrocardiogram (Ecg) Performed",
      "system" : "urn:oid:2.16.840.1.113883.6.13"
    }, {
      "code" : "89.52",
      "display" : "Electrocardiogram",
      "system" : "http://hl7.org/fhir/sid/icd-9-cm"
    }, {
      "code" : "4A02X4Z",
      "display" : "Measurement of Cardiac Electrical Activity, External Approach",
      "system" : "urn:oid:2.16.840.1.113883.6.4"
    } ]
  },
  "performed" : {
    "dateTime" : "2014-03-29T09:15:22-12:00"
  },
  "status" : "completed",
  "resourceType" : "Procedure",
  "subject" : {
    "id" : "patient",
    "resourceType" : "Patient"
  }
}
C-CDA Equivalent: ``xml 
                Procedures Section (entries required) (V2)                                                  Procedures                 Date                 Status              
          
                                       12 lead ECG                 03/29/2014 9:15PM UTC                 completed              
          
       
                                                                                                                                                               
 ``