Download Procedure Note (V3)

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