1. 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

2. Postprocedure Diagnosis Section (V3)
Postprocedure Diagnosis (V3)
Problem Observation (V3) (one or more)
Problem Type code (SNOMED – 8 options)
Value (Problem) – (SNOMED subset)
(optional) – ICD10CM

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

4. Complications Section (V3)
Problem Observation (V3)
Problem Type code (SNOMED – 8 options)
Value (Problem) – (SNOMED subset)
(optional) – ICD10CM

5. Procedure Indications Section (V2)
(optional) Indication (V2)
Problem Type code - (SNOMED – 8 options)
Value (Problem) – (SNOMED subset)
(optional) – ICD10CM

6. 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
SHOULD be selected from LOINC (CodeSystem: ) or SNOMED CT (CodeSystem: ), and MAY be selected from CPT-4 (CodeSystem: ) or ICD10 PCS (CodeSystem: ) or CDT-2 (Code System: ) (CONF: ).
Procedure Activity Act (V2)
This template represents any act that cannot be classified as an observation or procedure according to the HL7 RIM.