Procedure Note (V3) ** = Required sections

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Presentation transcript:

Procedure Note (V3) ** = Required sections Allergies and Intolerances Section (entries optional) (V3) Anesthesia Section (V2) Assessment and Plan Section (V2) Assessment Section Chief Complaint and Reason for Visit Section Chief Complaint Section Complications Section (V3)** Family History Section (V3) History of Past Illness Section (V3) History of Present Illness Section Medical (General) History Section Medications Administered Section (V2) Medications Section (entries optional) (V2) Physical Exam Section (V3) Plan of Treatment Section (V2) Planned Procedure Section (V2) Postprocedure Diagnosis Section (V3)** Procedure Description Section** Procedure Disposition Section Procedure Estimated Blood Loss Section Procedure Findings Section (V3) Procedure Implants Section Procedure Indications Section (V2)** Procedure Specimens Taken Section Procedures Section (entries optional) (V2) Reason for Visit Section Review of Systems Section Social History Section (V3) US Realm Date and Time (DT.US.FIELDED) ** = Required sections

Postprocedure Diagnosis Section (V3) Postprocedure Diagnosis (V3) Problem Observation (V3) (one or more) Problem Type code (SNOMED – 8 options) Value (Problem) – (SNOMED subset) - 2.16.840.1.113883.3.88.12.3221.7.4 (optional) Translation @code – ICD10CM

Procedure Description Section Unstructured narrative section. Only contains CDA infrastructure, Title, and Text

Complications Section (V3) Problem Observation (V3) Problem Type code (SNOMED – 8 options) Value (Problem) – (SNOMED subset) - 2.16.840.1.113883.3.88.12.3221.7.4 (optional) Translation @code – ICD10CM

Procedure Indications Section (V2) (optional) Indication (V2) Problem Type code - (SNOMED – 8 options) Value (Problem) – (SNOMED subset) - 2.16.840.1.113883.3.88.12.3221.7.4 (optional) Translation @code – ICD10CM

Procedures Section (entries optional) (V2) May include: Procedure Activity Procedure (V2) This template represents procedures whose immediate and primary outcome (post- condition) is the alteration of the physical condition of the patient. Procedure Activity Observation (V2) This template represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM This @code SHOULD be selected from LOINC (CodeSystem: 2.16.840.1.113883.6.1) or SNOMED CT (CodeSystem: 2.16.840.1.113883.6.96), and MAY be selected from CPT-4 (CodeSystem: 2.16.840.1.113883.6.12) or ICD10 PCS (CodeSystem: 2.16.840.1.113883.6.4) or CDT-2 (Code System: 2.16.840.1.113883.6.13) (CONF:1098-19202). Procedure Activity Act (V2) This template represents any act that cannot be classified as an observation or procedure according to the HL7 RIM.