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Procedures Section

Template ID: 2.16.840.1.113883.10.20.22.2.7.1 Version: R2.1 (2014-06-09) Badge: Core Section

Overview

The Procedures Section documents surgical, diagnostic, and therapeutic procedures performed on or for the patient. This section provides a comprehensive record of interventions and procedures that are clinically significant for patient care.

Clinical Purpose and Context

The Procedures Section records: - Surgical procedures (e.g., appendectomy, knee replacement) - Diagnostic procedures (e.g., colonoscopy, cardiac catheterization) - Therapeutic procedures (e.g., physical therapy, dialysis) - Procedure dates and status - Performing provider information - Body sites and laterality

This information is essential for: - Understanding patient's surgical history - Identifying procedures relevant to current conditions - Coordinating post-procedure care - Supporting billing and coding - Meeting quality reporting requirements - Care planning and clinical decision-making

When to Include

The Procedures Section is commonly included in: - Continuity of Care Documents (CCD) - Discharge Summaries - Operative Notes - Consultation Notes - Transfer Summaries - History and Physical Notes

The section may be optional in some document types but is highly recommended when procedures have been performed or are clinically relevant to the patient's history.

Template Details

Official OID

  • Root: 2.16.840.1.113883.10.20.22.2.7.1
  • Extension: 2014-06-09 (R2.1 and R2.0)

Conformance Level

  • Conformance: MAY or SHOULD (depending on document type; SHALL in operative notes)
  • Section Code: 47519-4 (LOINC - "History of Procedures")

Cardinality

  • Section: 0..1 (Optional in most document types, required in operative notes)
  • Entries: 1..* (If section is present, at least one Procedure Activity entry is required)
  • Procedure Activity Procedure (V2): 2.16.840.1.113883.10.20.22.4.14:2014-06-09
  • Procedure Activity Observation (V2): 2.16.840.1.113883.10.20.22.4.13:2014-06-09
  • Procedure Activity Act (V2): 2.16.840.1.113883.10.20.22.4.12:2014-06-09

Protocol Requirements

The ProcedureProtocol defines the data contract for procedure entries. Each procedure must provide:

Required Properties

Property Type Description
name str Procedure name/description
code str Procedure code
code_system str Code system: 'SNOMED CT', 'CPT-4', 'LOINC', 'ICD10 PCS', etc.
status str Status: 'completed', 'active', 'aborted', 'cancelled'

Optional Properties

Property Type Description
date Optional[date \| datetime] Date/time when procedure was performed
target_site Optional[str] Target body site description
target_site_code Optional[str] SNOMED CT code for target body site
performer_name Optional[str] Name of person/entity who performed procedure

Data Types and Constraints

  • name: Free-text procedure description (e.g., "Appendectomy", "Colonoscopy")
  • code: Must be from an appropriate code system (LOINC, SNOMED CT, CPT-4, ICD10 PCS, HCPCS, CDT-2)
  • code_system: Name of the code system
  • status: Reflects completion state of the procedure
  • date: Can be date or datetime; use datetime for surgical procedures with specific timing
  • target_site: Body location where procedure was performed (e.g., "Right knee", "Abdomen")
  • target_site_code: SNOMED CT anatomical site code
  • performer_name: Provider who performed the procedure

Code Example

Here's a complete working example using ccdakit to create a Procedures Section:

from datetime import date, datetime
from ccdakit.builders.sections.procedures import ProceduresSection
from ccdakit.core.base import CDAVersion

# Define a procedure using a simple class that implements ProcedureProtocol
class Procedure:
    def __init__(self, name, code, code_system, status, date=None,
                 target_site=None, target_site_code=None, performer_name=None):
        self._name = name
        self._code = code
        self._code_system = code_system
        self._status = status
        self._date = date
        self._target_site = target_site
        self._target_site_code = target_site_code
        self._performer_name = performer_name

    @property
    def name(self):
        return self._name

    @property
    def code(self):
        return self._code

    @property
    def code_system(self):
        return self._code_system

    @property
    def status(self):
        return self._status

    @property
    def date(self):
        return self._date

    @property
    def target_site(self):
        return self._target_site

    @property
    def target_site_code(self):
        return self._target_site_code

    @property
    def performer_name(self):
        return self._performer_name

# Create procedure instances
procedures = [
    Procedure(
        name="Appendectomy",
        code="80146002",
        code_system="SNOMED CT",
        status="completed",
        date=datetime(2022, 5, 15, 10, 30),
        target_site="Abdomen",
        target_site_code="818983003",
        performer_name="Dr. Sarah Johnson"
    ),
    Procedure(
        name="Colonoscopy",
        code="73761001",
        code_system="SNOMED CT",
        status="completed",
        date=date(2023, 8, 20),
        target_site="Colon",
        target_site_code="71854001",
        performer_name="Dr. Michael Chen"
    ),
    Procedure(
        name="Total knee replacement",
        code="609588000",
        code_system="SNOMED CT",
        status="completed",
        date=date(2021, 3, 10),
        target_site="Right knee",
        target_site_code="72696002",
        performer_name="Dr. Emily Rodriguez"
    ),
    Procedure(
        name="Cardiac catheterization",
        code="41976001",
        code_system="SNOMED CT",
        status="completed",
        date=datetime(2023, 1, 5, 14, 0),
        target_site="Heart",
        target_site_code="80891009",
        performer_name="Dr. James Williams"
    )
]

# Build the Procedures Section
section_builder = ProceduresSection(
    procedures=procedures,
    title="Procedures",
    version=CDAVersion.R2_1
)

# Generate XML element
section_element = section_builder.build()

# Convert to XML string (for demonstration)
from lxml import etree
xml_string = etree.tostring(section_element, pretty_print=True, encoding='unicode')
print(xml_string)

Official Reference

For complete specification details, refer to the official HL7 C-CDA R2.1 documentation: - HL7 C-CDA R2.1 Implementation Guide - Section: 5.44 - Procedures Section (entries required)

Best Practices

Common Patterns

  1. Use Appropriate Code Systems
  2. SNOMED CT: Broad coverage of clinical procedures
  3. CPT-4: US billing and administrative codes
  4. LOINC: Laboratory and diagnostic procedures
  5. ICD10 PCS: Inpatient hospital procedures (US)

  6. Choose based on use case and regional requirements

  7. Document Clinically Significant Procedures

  8. Include procedures relevant to current care
  9. Major surgical procedures
  10. Diagnostic procedures with significant findings
  11. Therapeutic procedures affecting treatment plan

  12. Consider excluding routine minor procedures unless relevant

  13. Specify Target Sites with Laterality

  14. Include body site when relevant
  15. Specify laterality (left/right) when applicable
  16. Use SNOMED CT codes for consistency

  17. Example: "Right knee" not just "knee"

  18. Include Performer Information

  19. Document performing provider when known
  20. Important for care coordination
  21. Supports follow-up and consultation

  22. May be required for billing

  23. Use Precise Date/Time When Available

  24. Surgical procedures: use datetime with time
  25. Historical procedures: date may be sufficient
  26. Precision supports timeline reconstruction
  27. Important for perioperative care

Validation Tips

  1. Section Code Validation
  2. Ensure section code is 47519-4 (LOINC "History of Procedures")

  3. This is automatically set by the builder

  4. Template ID Validation

  5. Verify template ID includes extension="2014-06-09"

  6. Same extension used for both R2.1 and R2.0

  7. Procedure Activity Type Selection

  8. Three templates available: Procedure, Observation, Act
  9. Most surgical/diagnostic procedures use Procedure template
  10. Educational activities may use Act template

  11. Choose appropriate template for procedure type

  12. Code System OID Mapping

  13. Verify code system OIDs are correct:

    • SNOMED CT: 2.16.840.1.113883.6.96
    • CPT-4: 2.16.840.1.113883.6.12
    • LOINC: 2.16.840.1.113883.6.1
    • ICD10 PCS: 2.16.840.1.113883.6.4

  14. Status Code Validation

  15. Use appropriate status codes
  16. 'completed' for finished procedures
  17. 'active' for ongoing procedures (rare)
  18. 'aborted' for procedures started but not completed
  19. 'cancelled' for procedures cancelled before starting

Gotchas to Avoid

  1. Missing Procedure Dates
  2. While optional in protocol, dates are highly recommended
  3. Procedures without dates have limited clinical value

  4. Use nullFlavor only when date is truly unknown

  5. Incorrect Code System Selection

  6. Don't use ICD-10-CM for procedures (diagnosis codes)
  7. Use ICD10 PCS for inpatient procedures
  8. CPT-4 for outpatient/professional services

  9. SNOMED CT works across settings

  10. Incomplete Body Site Information

  11. Specify laterality when applicable
  12. "Knee replacement" → "Right knee replacement"
  13. Missing laterality can lead to errors

  14. Use target_site_code for structured representation

  15. Overly Broad Procedure Descriptions

  16. Use specific codes when available
  17. "Surgery" is too vague
  18. "Laparoscopic appendectomy" better than "abdominal surgery"

  19. Specificity supports quality measurement

  20. Confusing Procedure Status

  21. Most historical procedures should be 'completed'
  22. 'active' is for ongoing procedures (e.g., chemotherapy series)
  23. Don't use 'active' for planned future procedures

  24. Use Care Plan section for future procedures

  25. Date Format Inconsistencies

  26. Use Python date or datetime objects
  27. Builder handles CDA formatting
  28. Don't mix dates and datetimes inconsistently

  29. Consider clinical context for precision needs

  30. Missing Performer for Significant Procedures

  31. Document surgeon for major procedures
  32. Supports follow-up care
  33. May be required for specific document types

  34. Can use organization if individual unknown

  35. Duplicate Procedure Entries

  36. Avoid documenting same procedure multiple times
  37. If procedure has multiple stages, consider using episode ID

  38. Consolidate when reconciling from multiple sources

  39. Including Non-Procedures

  40. Don't include observations as procedures
  41. Lab tests go in Results section, not Procedures
  42. Physical exam findings go in Physical Exam section

  43. Medication administration goes in Medications section

  44. Implant Information

    • For procedures involving implants, consider using device observation
    • UDI (Unique Device Identifier) may be required
    • Important for recalls and tracking

  45. Procedure Context

    • Consider documenting indication/reason for procedure
    • Can use entryRelationship with indication observation
    • Links procedure to problem/condition

  46. Historical Data Quality

    • Patient-reported procedures may lack detail
    • Document information source
    • May need to verify with medical records
    • Use appropriate nullFlavors for missing data

  47. Narrative-Entry Consistency

    • Ensure narrative table matches structured entries
    • Builder handles this automatically
    • Include key details: date, site, performer in narrative

  48. Procedure Complications

    • Consider documenting significant complications
    • Can use entryRelationship with problem observation
    • Important for complete clinical picture