Stream: C-CDA
Topic: Procedure Section Types
Dave Carlson (MIE) (Feb 03 2021 at 19:27):
There are three different procedure sections in CCDA...
2.16.840.1.113883.10.20.22.4.14 (procedure) - This clinical statement represents procedures whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the patient. Examples of these procedures are an appendectomy, hip replacement and a creation of a gastrostomy.
2.16.840.1.113883.10.20.22.4.13 (observation) - This clinical statement represents procedures that result in new information about the patient that cannot be classified as a procedure according to the HL7 RIM. Examples of these procedures are diagnostic imaging procedures, EEGs and EKGs.
2.16.840.1.113883.10.20.22.4.12 (act) - This clinical statement represents any procedure that cannot be classified as an observation or a procedure according to the HL7 RIM. Examples of these procedures are a dressing change, teaching or feeding a patient or providing comfort measures.
The splits for the most part make sense to me.
The question I have with them is, from a schematron/validation standpoint, is there any checking or "lists" (valusets?) of what codes are "valid" for each section? Or is it more of a "the person making the document decides which 'bucket' they belong in"?
Dave Carlson (MIE) (Feb 16 2021 at 17:48):
To be a bit more on point... if there is nothing schematically limiting it, then, there is nothing stopping someone from putting a "Hip Replacment" in the 22.4.12 section, or an EKG in the 22.4.14, etc.
I guess from that perspective, there are a lot of ways places can (and obviously do) make "poor" C-CDAs, and at a certain point, we can't "stop" them per se. I just didn't know if this was an area where there are some (at least from a certification/validation standpoint) things that have been (or opinions on should be?) done?
Last updated: Apr 12 2022 at 19:14 UTC
