A_Procedure Tabular View

UKCT_RM144010UK01

Procedure

Information about clinical statements that are procedures.

A procedure can either be a procedure that has happened or a procedure that is planned.

Used by:

[1..1] classCode (CS {CNE:PROC} ){ Fixed="PROC " }

Indicates that this is a procedure.

Fixed value: "PROC"

[1..1] moodCode (CS {CNE:x_ActMoodIntentEvent} )

The mood code of the procedure.

The value of mood code should be set according to the information and context of the clinical statement information being carried in the procedure class. The Coded Only datatype flavour is used to carry this information as follows:

The code attribute will contain a value from the list of codes in the x_ActMoodIntentEvent vocabulary.

[1..2] id (LIST<II>)

A list of identifiers for this instance of a procedure.

The first is mandatory and is the unique national identifier for this instance of a specific clinical statement. The second is optional and allows a procedure to be identified by a local identifier.

The Identifier Global datatype flavour is used to carry the first identifier as follows:

The root attribute shall contain a DCE UUID

The Identifier External datatype flavour is used to carry the second identifier as follows:

The root carries an OID for the local identifier scheme
The extension carries a human-readable identifier

[1..1] code (CD {CNE:ProcedureTypeSnCT} )

A SnomedCT code identifying the Procedure type.

The Concept Descriptor (CD) dataype shall be used to carry this information as follows:

The code attribute shall contain a code from the relevant vocabulary
The code System attribute shall contain the OID for SnomedCT
The display text shall carry a description associated with the code in SnomedCT
the original text attribute may be used if required
qualifier(s) may be used if required.

[0..1] statusCode (CS {CNE:ActStatus} )

The (optional) status of the Procedure, e.g. active, suspended, completed.

Required if status is aborted or cancelled.

The Coded Only datatype flavour is used to carry this information as follows:

The code attribute will contain a value from the list of codes in the Act Status vocabulary.

[1..1] effectiveTime (IVL<TS>)

The date and time at which / during which that the patient had the procedure if it has already happened or a future date and time at which / during for which a procedure is planned.

The clinically relevant date and time.

A date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

The low attribute shall contain the start date
The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

The low attribute shall contain the start date.

If only an end date is present the Date or Time Interval Before datatype shall be used:

The high attribute shall contain the end date.

If the exact date is not known then the Center attribute can be used

The center attribute shall contain a time stamp

[0..*] performer

Refers to a performer of the procedure.


[1..1] typeCode (CS {CNE:PRF} ){ Fixed="PRF " }		Indicates the role of performer Fixed value: "PRF"

[1..1] contextControlCode (CS {CNE:OP} ){ Fixed="OP " }		A code that specifies how this Participation contributes to the context of the current Act and whether it may be propagated to descendent Acts whose association allows such propagation. Fixed value: "OP" - Overriding and propagating "O" (Overriding) - the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating) - the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true"

[1..1] time (IVL<TS>)		The time during / at which the performer performed the procedure or will perform the procedure.

[0..1] modeCode (CS {CNE:ParticipationMode} )		The mode in which the participant participated in the procedure. Required if not "ELECTRONIC" The Coded Only datatype flavour is used to carry this information as follows: The code attribute will contain a value from the list of codes in the ParticipationMode vocabulary.

[1..1] role (RoleChoice)		The person or device performing this prcedure.

[0..1] author

Refers to the person or device responsible for authorising the procedure.


[1..1] typeCode (CS {CNE:AUT} ){ Fixed="AUT " }		Indicates the role of author of this procedure. Fixed value: "AUT"

[1..1] contextControlCode (CS {CNE:OP} ){ Fixed="OP " }		A code that specifies how this Participation contributes to the context of the current Act and whether it may be propagated to descendent Acts whose association allows such propagation. Fixed value: "OP" - Overriding and propagating "O" (Overriding) - the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating) - the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true"

[1..1] time (TS)		When the author authorised the procedure.

[0..1] modeCode (CS {CNE:ParticipationMode} )		The mode in which the author participated in the procedure. Required if not "ELECTRONIC" The Coded Only datatype flavour is used to carry this information as follows: The code attribute will contain a value from the list of codes in the ParticipationMode vocabulary.

[1..1] role (RoleChoice)		The person or device who / which is the author.

[0..1] informant

Refers to the person or device acting in the role of informant. The patient may act as an informant.


[1..1] typeCode (CS {CNE:INF} ){ Fixed="INF " }		Indicates that the role is that of informant. Fixed value: "INF"

[1..1] contextControlCode (CS {CNE:OP} ){ Fixed="OP " }		A code that specifies how this Participation contributes to the context of the current Act and whether it may be propagated to descendent Acts whose association allows such propagation. Fixed value: "OP" - Overriding and propagating "O" (Overriding) - the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating) - the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true"

[1..1] time (IVL<TS>)		The time during / at which the informant gave the information.

[0..1] modeCode (CS {CNE:ParticipationMode} )		The mode in which the informant gave the information. Required if not "ELECTRONIC" The Coded Only datatype flavour is used to carry this information as follows: The code attribute will contain a value from the list of codes in the ParticipationMode vocabulary.

[1..1] role (RoleChoice)		The person or device which / who is the informant.

[0..*] product

A reference to something produced by this Procedure, e.g. a specimen.


[1..1] typeCode (CS {CNE:PRD} ){ Fixed="PRD " }	Indicates this is a product Fixed value: "PRD"

[1..1] contextControlCode (CS {CNE:OP} ){ Fixed="OP " }	A code that specifies how this Participation contributes to the context of the current Act and whether it may be propagated to descendent Acts whose association allows such propagation. Fixed value: "OP" - Overriding and propagating "O" (Overriding) - the association replaces any context of the same or more specific type that has been conducted from the parent act. "P" (Propagating) - the association is conducted to all child acts where the ActRelationship.contextConductionInd is set to "true"


[1..1] specimenRole (SpecimenRole)	A link to the specimen role which is a product of the procedure.

[0..*] pertinentInformation5

Medication which is pertinent to the procedure.


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates pertinent information.. Fixed value: "PERT"

[1..1] inversionInd (BL)		An indicator specifying that the ActRelationship.typeCode should be interpreted as if the roles of the source and target Acts were reversed. The inversion indicator is used when the meaning of ActRelationship.typeCode must be reversed. In this context the inversionInd is is fixed at "false" indicating that the meaning of ActRelationship.typeCode is not reversed.

[1..1] contextConductionInd (BL)		If true, associations in the parent act are conducted across the ActRelationship to the child act. In this context the contextConductionInd defaults to "true".

[0..1] sequenceNumber (INT)		An optional integer to allow relative ordering of this relationship among other like-types relationships having the same source Act.

[1..1] negationInd (BL)		When "true" allows the sender to specifically state that the semantic of the relationship is negated In this case the negationInd is fixed at "false"

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be "true" otherwise the value shall be "false". The value of seperatableInd shall be evaluated for each usage of the pertinentInformation relationship. In this context the seperatableInd defaults to "true".

[1..1] templateId (II)		An identifier of the Act Relationship that supports the linkage of clinical statements using the "Direct Relationship" mechanism. The Identifier External datatype flavour is used to carry this information as follows: The root attribute shall contain the OID "2.16.840.1.113883.2.1.3.2.4.18.2" The extension shall contain the template ID "CSAB_RM-NPfITUK10.sourceOf2".

[1..1] target (MedicationChoice)		A link to the choice of medication CMETs.

[0..1] pertinentInformation4

Refers to supporting information which is pertinent to the procedure.


[1..1] typeCode (CS {CNE:PERT} ){ Fixed="PERT " }		Indicates pertinent information.. Fixed value: "PERT"

[1..1] contextConductionInd (BL)		If true, associations in the parent act are conducted across the ActRelationship to the child act. In this context the contextConductionInd is fixed at "true".

[1..1] seperatableInd (BL)		This attribute indicates whether or not the source Act is intended to be interpreted independently of the target Act. If the source act is intended to be interpreted independently the value shall be 'true' otherwise the value shall be 'false'. In this context the seperatableInd is fixed at "false".

[1..1] pertinentSupportingInfo (SupportingInfo)		A code and/or effective time and/or text and/or value that is pertinent to the clinical statement

RoleChoice

The person or device performing this procedure

Used by: Procedure

[1..1] either : UKCT_MT120601UK02

A CMET identifying the participating device.

AgentDevice.classCode shall carry a fixed value of "AGNT"

AgentDevice. id shall carry a nationally agreed identifier for the role being played. This shall be a code from a national coding scheme.

A national code is carried in the following way:

The root attribute shall contain the OID that identifies the coding scheme
The extension attribute shall contain the code

If the device can be identified by reference to SDS then

DeviceSDS.classcode shall carry a fixed value of "DEV" to indicates that this is a Device. In this context the device can be hardware or software.

DeviceSDS.determinerCode shall carry a fixed value of "INSTANCE"

DeviceSDS.id shall carry an SDS identifier that uniquely identifies the Device.

This is carried in the following way.

The root attribute shall contain an OID with the appropriate value
The extension attribute shall contain the SDS Device ID

If the device cannot be identified by reference to SDS then

Device.classCode shall carry a fixed value of "DEV"

Device.determinerCode shall carry a fixed value fof "INSTANCE"

Device.id shall carry an optional identifier that uniquely identifies the Device. This shall be a code from a national scheme.

A national code is carried in the following way:

The root attribute shall carry the OID that identifies the coding scheme
The extension attribute shall contain the code

If an id is not present, then a name shall be included .

Device.code shall carry an optional code to describe the type of device.

If a code is not present, then a desc shall be included.

Device.name shall carry an optional name of the device.

This shall be included if an id is not present.

Device.desc shall carry an optional description of the type of device.

This shall be included if a code is not present.

Device.manufacturerModelName shall optionally carry the model name as allocated by the Device manufacturer.

Device.softwareName shall optionally carry the name of the software used by the Device.

If the device is scoped by an organization then and the organizaton can be identified by reference to SDS then

OrganizationSDS.classCode shall carry a fixed value of "ORG"

OrganizationSDS.determinerCode shall carry a fixed value of "INSTANCE".

OrganizationSDS.id shall carry an SDS identifier that uniquely identifies the Organization.This is carried in the following way:

The root attribute shall contain an OID with the value 1.2.826.0.1285.0.1.10
The extension attribute shall contain the SDS Organization ID

If the device is scoped by an organization then and the organizaton cannot be identified by reference to SDS then

Organization.classCode shall carry a fixed value of "ORG"

Organization.determinerCode shall carry a fixed value of "INSTANCE"

Organization.id shall carry an optional identifier that uniquely identifies the Organization.This shall be a code from a national scheme.

A national code is carried in the following way:

the root attribute shall contain the OID that identifies the coding scheme
the extension attribute shall contain the code

If an id is not present, then a name shall be included.

Organization.code shall optionally carry a value from the OrganizationType vocabualary to identfy the type of Organization.

The Coded Only datatype flavour is used to carry this information as follows:

The code attribute shall contain a value from the list of codes in the OrganizationType vocabulary.

If a code is not present, then a desc shall be included.

Organization.name shall optionally contain the name of the Organization. This shall be included if an id is not present.

Organization.desc shall contain a optional description of the type of Organization. This shall be included if a code is not present.

Organization.telecom shall contain optional telephone contact details for the Organization.

Organization.addr shall contain an optional address of the Organization

... or ... : UKCT_MT142101UK01

NPfIT CMET to identify the person who is participating.

The tabular view for this CMET describes its usage.

SpecimenRole

Information about the specimen.

Used by: Procedure

[1..1] classCode (CS {CNE:SPEC} ){ Fixed="SPEC " }

Indicates that this is a specimen.

Fixed value: "SPEC"

[0..1] id (II)

Local identifier of a specimen.

The local identifier is carried using the Identifier External datatype flavour as follows:

The extension attribute shall contain the local id
The root attribute shall contain an OID for the local id. system

[0..1] code (CE {CWE:RoleCode} )

The type of specimen.

Fixed value: "P" - taken from the patient

[0..1] specimenMaterial (Material)

Refers to the specimen material

MedicationChoice

A choice of CMETs that represent various kinds of statements that can be made about the administration and supply of medication with regards to this procedure.

Used by: Procedure

[1..1] either : UKCT_MT140701UK03

A CMET that represents a scheduled / ongoing / ended administration of a complete course of medication

... or ... : UKCT_MT140201UK03

A CMET that represents a scheduled / ongoing / ended administration of a single dose of medication

... or ... : UKCT_MT140501UK03

A CMET that represents the planned / ongoing / completed supply of medication to the patient / patient's representative /clinician.

SupportingInfo

An Act holding overflow information from the Act acting as the root of the clinical statement. Supporting information shall not contradict the content of the source act, only add to it or explain it.

Used by: Procedure

[1..1] classCode (CS {CNE:OBS} ){ Fixed="OBS " }

Indicates that this is an observation.

Fixed value: "OBS"

[1..1] moodCode (CS {CNE:EVN} ){ Fixed="EVN " }

Indicates this is an event

Fixed value: "EVN"

[0..1] code (CV {CNE:SnomedCT} )

A SnomedCT code indicating the nature of the supporting information.

The Coded Plain flavour of the Coded Value (CV) datatype shall be used to carry this information as follows:

The code attribute shall contain a value from the list of codes in the vocabulary
The code System attribute shall contain the OID for SnomedCT
The display text attribute will carry a description for the code from the coding system .

[0..1] effectiveTime (IVL<TS>)

A clinically relevant date and time that forms supporting information.

The date range shall be carried as follows:

If both a start date and an end date are present the Date or Time Interval Complete datatype shall be used:

The low attribute shall contain the start date
The high attribute shall contain the end date.

If only a start date is present the Date or Time Interval After datatype shall be used:

The low attribute shall contain the start date.

If only an end date is present the Date or Time Interval Before datatype shall be used:

The high attribute shall contain the end date.

[0..1] value (ANY)

The value of the observation.

Material

Information about the actual specimen taken.

Used by: SpecimenRole

[1..1] classCode (CS {CNE:MAT} ){ Fixed="MAT " }

Indicates a material.

Fixed value: "MAT"

[1..1] determinerCode (CS {CNE:EntityDeterminer} )

The determiner code of the entity.

The value of determinerCode should be set according to the specification of the specimen being carried in the entity.

The CodedOnly datatype flavour is used to carry this information as follows:

The code attribute will contain a value from the list of codes in the EntityDeterminer vocabulary;

[0..1] id (II)

An optional identifier of the material. This attribute may only be used if the determinerCode is "INSTANCE"

The Identifier Global datatype flavour is used to carry this information as follows:

The root attribute shall contain a DCE UUID.

[0..1] code (CE {CNE:SpecimenMaterialTypeSnCT} )

A SnomedCT code identifying the material forming the specimen.

The datatype must be constrained to CD and used as indicated below.

The Concept Descriptor (CD) datatype shall be used to carry this information as follows:

The code attribute shall contain a code from the relevant vocabulary
The code System attribute shall contain the OID for SnomedCT
The display text shall carry a description associated with the code in SnomedCT
the original text attribute may be used if required
qualifier(s) may be used if required

A_Procedure - tabular view