Transfer of Care
Domain Message Specification

Version: 1.0; Status: RC1

Procedure Tabular View

COCD_TP146066GB01
Procedure

This template class constrains the CDA Procedure entry class.

The therapeutic procedure performed.

This could include site and must include laterality where applicable.The value attribute will carry the details of the procedure.

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

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as a procedure.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "PROC".
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as an event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN".
[1..1] [M] code (CD { CNE:ProcedureTypeSnCT } )

Model Attribute Description

The HL7 attribute value uses one or more SNOMED CT concepts to describe the procedure.

Implementation in XML Instance

The Concept Descriptor (CD) data type shall be used to carry this information in the XML element value as follows:

  • The XML attribute code shall contain a value from the ProcedureTypeSnCT vocabulary.
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"
  • The XML attribute displayName shall carry the description associated with the SNOMED CT concept. It is recommended that the preferred term is used.
  • The XML attribute originalText can be used to carry an XML element reference. This can be used to link the coded item to the relevant text in the CDA section
  • The XML element qualifier may be populated if post coordination or translation is required. For further information, see the CD data type guidance linked on the left hand side.
[1..1] [R] effectiveTime (IVL<TS>)

Model Attribute Description

The HL7 attribute effectiveTime is used for when that procedure was performed. This may be either an interval or a timestamp.

Implementation in XML Instance

If an interval is recorded then:

The Interval of Points in Time data type flavour is used to carry this information in the XML element effectiveTime using the value attributes of the of the XML elements low and high.

The date range shall be carried as follows:

The XML attribute value of the XML elements low and high, shall be populated with a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

  • yyyy is the year
  • mm is the month
  • dd is the day
  • hh is the hour
  • mm is the minute
  • ss is seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.

The Time Interval Complete data type shall be used:
  • The XML attribute value of the XML element low shall be populated with a 'start date' time stamp to indicate the onset of the illness or disease
  • The XML attribute value of the XML element high may be populated with an 'end date' time stamp to indicate when the illness or disease was no longer present.

The XML attribute value of the XML elements low and high should be populated to the level of detail that is available on the sending system.

If a time stamp is recorded then:

The XML attribute value of the XML element effectiveTime shall be populated with the time of the procedure using a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

  • yyyy is the year
  • mm is the month
  • dd is the day
  • hh is the hour
  • mm is the minutes
  • ss is the seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.

Where no time is recorded or available then:

  • The XML attribute nullFlavor of the XML element time shall contain the value "UNK"
[1..1] [M] id (II)

Model Attribute Description

The HL7 attribute id uses an identifier to identify the instance of a procedure.

Implementation in XML Instance

The Identifier Global data type flavour is used to carry this information in the XML element id as follows:

  • The XML attribute root shall contain a DCE UUID.
[1..1] [M] statusCode (CS { CNE:ActStatus } )
{ Fixed="completed" }

Model Attribute Description

The HL7 attribute code uses a code to describe the status of the procedure.

Implementation in XML Instance

The Coded Simple (CS) data type shall be used to carry this information in the XML element code as follows:

  • The XML attribute code shall contain the fixed value of "completed".
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146066GB01#Procedure" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146066GB01#Procedure".
[0..1] author

This template class constrains the CDA author class.

The author of this procedure information must be included if the author is different to the document (inherited) author.

If there is no known author for the information held on the source system then:

  • The information may be included and the document author will be deemed to be the author (by inheritance). The author should be asked to decide whether this is acceptable or not.
  • If the document author does not want to be considered as the author of the information then information must not be included in the document.
[1..1] [M] typeCode (CS { CNE: ParticipationType } )
{ Fixed="AUT" }

Model Attribute Description

The HL7 attribute typeCode describes this class as an author participation.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "AUT".
[1..1] [M] contextControlCode (CS { CNE: ContextControl } )
{ Fixed="OP" }

Model Attribute Description

The HL7 attribute contextControlCode uses a set of codes from the HL7 vocabulary ContextControl to determine whether participations associated with the parent act are conducted across to the child act (also associated with the child act). This set of codes also determine how these participations conduct.

The conduction can only take place if the contextConductionInd in the actRelationships is set to "true".

The value of this attribute is fixed in the HL7 model to "OP":

  • "O" (Overriding) - the author replaces any author that has been conducted from any previous acts.
  • "P" (Propagating) - the author is conducted to all child acts where the contextConductionInd is set to "true".

Implementation in XML Instance

  • The XML attribute contextControlCode shall contain the value "OP"
[1..1] [M] contentId (II) { "NPFIT-300001#Role" }

Model Attribute Description

The HL7 (NHS localisation) attribute contentId, when valued in an instance, provides a unique forward pointing identifier for the template which constrains the classes and attributes which follow, for NHS use.

The attribute is intended simply as a structural navigational aid and should not be relied upon as an indicator of semantic meaning. The contentId is populated at run time with a value from the allowed list contained in the model.


Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element contentId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.16"
  • The XML attribute extension shall contain one of the allowed template artefact identifiers.
[1..1] [M] functionCode (CV { CNE:AuthorFunctionType } )
{ Fixed="OA" }

Model Attribute Description

The HL7 attribute functionCode uses a code from the vocabulary AuthorFunctionType to describe the function of the author

Implementation in XML Instance

The Coded Plain data type flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element functionCode as follows:

  • The XML attribute code is fixed to "OA"
  • The XML attribute codeSystem is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.17.178"
  • The XML attribute displayName is fixed to the author's function name "Originating Author".
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146066GB01#author" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146066GB01#author".
[1..1] [R] time (TS)

Model Attribute Description

The HL7 attribute time is used to define the time the author originally recorded the procedure.

Implementation in XML Instance

The XML attribute value of the XML element time shall be populated with the time that author recorded the information using a time stamp in the format yyyymmddhhmmss[+|-ZZzz] where:

  • yyyy is the year
  • mm is the month
  • dd is the day
  • hh is the hour
  • mm is the minutes
  • ss is the seconds
  • [+|-ZZzz] is the time zone offset in hours and minutes

Sections from the right of this representation may be left off when the sending system does not record to this level of accuracy. When hours are present, the time zone offset must also be present.

Where no time is recorded or available then:

  • The XML attribute nullFlavor of the XML element time shall contain the value "UNK"
[1..1] participant (AuthorChoice)
A link to the choice of authors.
[0..*] entryRelationship

This template class constrains the CDA entryRelationship class.

This is a "Is etiology for" class. It is a type of has pertinent information in which the target observation is asserted to have been caused by a newly identified source (action, event or condition).

The assertion of a causal relationship is attributed to the author of the source observation.

In the context of this procedure template it i s that a complication occurred which was caused by or associated with the procedure. This class is used to link the procedure to the complication.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="CAUS" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe this class as a causal relationship.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "CAUS".
[1..1] [M] contextConductionInd (BL)
{ Fixed="true" }

Model Attribute Description

The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent act is conducted across to the child act (also associated with the child act).

Implementation in XML Instance

  • The XML attribute contextConductionInd is fixed to "true".
[1..1] [M] seperatableInd (BL)
{ Fixed="false" }

Model Attribute Description

The HL7 attribute seperatableInd uses a Boolean (true or false) to indicate whether two pieces of information can be interpreted separately.

Implementation in XML Instance

  • The XML attribute seperatableInd is fixed to "false".
[0..*] templateId (II)
{ Fixed="COCD_TP146066GB01#entryRelationship" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146066GB01#entryRelationship".
[1..1] causedComplication (Complication)
A link to the caused complication.
[0..*] entryRelationship1

This template class constrains the CDA entryRelationship class.

This is a "Is etiology for" class. It is a type of has pertinent information in which the target observation is asserted to have been caused by a newly identified source (action, event or condition).

The assertion of a causal relationship is attributed to the author of the source observation.

In the context of this procedure template it i s that an allergy or adverse reaction event occurred which was caused by anaesthetic agents including local anaesthesia used during the procedure. This class is used to link the procedure to the allergy or adverse reaction event or events.
[1..1] [M] typeCode (CS { CNE: ActRelationshipType } )
{ Fixed="CAUS" }

Model Attribute Description

The HL7 attribute typeCode uses a code to describe this class as a causal relationship.

Implementation in XML Instance

  • The XML attribute typeCode is fixed to "CAUS".
[1..1] [M] contextConductionInd (BL)
{ Fixed="false" }

Model Attribute Description

The HL7 attribute contextConductionInd uses a Boolean value (true or false) to determine whether information associated with the parent act is conducted across to the child act (also associated with the child act).

Implementation in XML Instance

  • The XML attribute contextConductionInd is fixed to "false".
[1..1] [M] seperatableInd (BL)
{ Fixed="false" }

Model Attribute Description

The HL7 attribute seperatableInd uses a Boolean (true or false) to indicate whether two pieces of information can be interpreted separately.

Implementation in XML Instance

  • The XML attribute seperatableInd is fixed to "false".
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146066GB01#entryRelationship1" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146066GB01#entryRelationship1".
[1..1] causedEventRef (EventRef)
A link to the caused event reference.
AuthorChoice

Refers to the choice of authors of the admission procedure.
Used by: Procedure
[1..1] : Template1

A link to the choice of author templates.
EventRef

This template class constrains the CDA Observation entry class.

This class represents a reference to any adverse reaction to any anaesthetic agents including local anaesthesia.

Used by: Procedure
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="OBS" }

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as an observation.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "OBS".
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as an event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN".
[1..1] [M] id (II)

Model Attribute Description

The HL7 attribute id uses an identifier to identify the instance of a allergy or adverse reaction coded information which must be carried in the same CDA document when this reference class is used.

Implementation in XML Instance

The Identifier Global data type flavour is used to carry this information in the XML element id as follows:

  • The XML attribute root shall contain a DCE UUID.
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146066GB01#causedEventRef" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146066GB01#causedEventRef".
Complication

This template class constrains the CDA Observation entry class.

This class details any intra-operative complications encountered during the procedure, arising during the patients stay in the recovery unit or directly attributable to the procedure.
Used by: Procedure
[1..1] [M] classCode (CS { CNE: ActClass } )
{ Fixed="OBS" }

Model Attribute Description

The HL7 attribute classCode uses a code to describe this class as an observation.

Implementation in XML Instance

  • The XML attribute classCode is fixed to "OBS".
[1..1] [M] moodCode (CS { CNE: ActMood } )
{ Fixed="EVN" }

Model Attribute Description

The HL7 attribute moodCode uses a code to describe this class as an event.

Implementation in XML Instance

  • The XML attribute moodCode is fixed to "EVN".
[1..1] [M] code (CV { CNE:SnomedCT } )
{ Fixed="116223007" }

Model Attribute Description

The HL7 attribute uses a SNOMED CT concept to describe this class as a complication.

Implementation in XML Instance

The Coded Plain flavour of Coded Value (CV) data type shall be used to carry this information in the XML element code as follows:

  • The XML attribute code shall carry the fixed value "116223007"
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"
  • The XML attribute displayName shall carry the description associated with the SNOMED CT concept. It is recommended that the preferred term is used.
  • The XML attribute originalText can be used to carry an XML element reference. This can be used to link the coded item to the relevant text in the CDA section
[1..1] [M] id (II)

Model Attribute Description

The HL7 attribute id uses an identifier to identify the instance of a diagnosis.

Implementation in XML Instance

The Identifier Global data type flavour is used to carry this information in the XML element id as follows:

  • The XML attribute root shall contain a DCE UUID.
[1..1] [M] templateId (II)
{ Fixed="COCD_TP146066GB01#causedComplication" }
Model Attribute Description

The HL7 attribute templateId provides a unique identifier for the template and the class name within that template. This is used to identify how the CDA standard has been constrained for NHS use.

Implementation in XML Instance

The Identifier External data type flavour is used to carry this information in the XML element templateId as follows:
  • The XML attribute root is fixed to the OID "2.16.840.1.113883.2.1.3.2.4.18.2"
  • The XML attribute extension is fixed to "COCD_TP146066GB01#causedComplication".
[1..1] [M] value (CV { CNE:FindingTypeSnCT } )

Model Attribute Description

The HL7 attribute value uses a SNOMED CT concept to describe the complication.

Implementation in XML Instance

The Coded Plain flavour of the Coded Value (CV) data type shall be used to carry this information in the XML element value as follows:

  • The XML attribute code shall contain a value from the FindingTypeSnCT vocabulary.
  • The XML attribute codeSystem shall contain the OID "2.16.840.1.113883.2.1.3.2.4.15"
  • The XML attribute displayName shall carry the description associated with the SNOMED CT concept. It is recommended that the preferred term is used.
  • The XML attribute originalText can be used to carry an XML element reference. This can be used to link the coded item to the relevant text in the CDA section