description: A Procedure Note encompasses many types of non-operative procedures including interventional cardiology, gastrointestinal endoscopy, osteopathic manipulation, and many other specialty fields. Procedure Notes are differentiated from Operative Notes because they do not involve incision or excision as the primary act.\n\nThe Procedure Note is created immediately following a non-operative procedure. It records the indications for the procedure and, when applicable, postprocedure diagnosis, pertinent events of the procedure, and the patients tolerance for the procedure. It should be detailed enough to justify the procedure, describe the course of the procedure, and provide continuity of care. package_name: hl7.fhir.us.ccda derivation: constraint name: ProcedureNote type: Composition elements: type: label: Procedure Note short: Procedure Note binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.6.1'} mustSupport: true index: 0 event: label: serviceEvent short: serviceEvent mustSupport: true index: 1 elements: period: short: period index: 2 elements: start: {short: start, index: 3} end: {short: end, index: 4} required: [start, end] required: [period] section: index: 5 slicing: rules: open discriminator: - {path: code, type: value} min: null slices: procedure_description_section: match: code: coding: - {code: 29554-3, system: 'http://loinc.org'} schema: label: Procedure Description Section short: Procedure Description Section mustSupport: true _required: true index: 12 elements: title: {short: title, mustSupport: true, index: 13} code: label: Procedure description short: Procedure description mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29554-3, system: 'http://loinc.org'} index: 14 text: {short: This section contains only human readable content, mustSupport: true, index: 15} required: [text, title, code] allergies_and_intolerances_section: match: code: coding: - {code: 48765-2, system: 'http://loinc.org'} schema: label: Allergies and Intolerances Section short: Allergies and Intolerances Section mustSupport: true index: 26 elements: title: {short: title, mustSupport: true, index: 27} code: label: Allergies and/or adverse reactions short: Allergies and/or adverse reactions mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 48765-2, system: 'http://loinc.org'} index: 28 text: {short: text, mustSupport: true, index: 29} entry: short: entry index: 30 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: allergies_and_intolerances_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance'] index: 31 required: [text, title, code] complications_section: match: code: coding: - {code: 55109-3, system: 'http://loinc.org'} schema: label: Complications Section short: Complications Section mustSupport: true _required: true index: 6 elements: title: {short: title, mustSupport: true, index: 7} code: label: Complications short: Complications mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 55109-3, system: 'http://loinc.org'} index: 8 text: {short: text, mustSupport: true, index: 9} entry: short: entry index: 10 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: complications_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 11 required: [text, title, code] chief_complaint_section: match: code: coding: - {code: 10154-3, system: 'http://loinc.org'} schema: label: Chief Complaint Section short: Chief Complaint Section mustSupport: true index: 52 elements: title: {short: title, mustSupport: true, index: 53} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10154-3, system: 'http://loinc.org'} index: 54 text: {short: This section contains only human readable content, mustSupport: true, index: 55} required: [text, title, code] assessment_and_plan_section: match: code: coding: - {code: 51847-2, system: 'http://loinc.org'} schema: label: Assessment and Plan Section short: Assessment and Plan Section. This section represents the clinician's conclusions and working assumptions that will guide treatment of the patient. The Assessment and Plan Section may be combined or separated to meet local policy requirements. mustSupport: true index: 36 elements: title: {short: title, mustSupport: true, index: 37} code: label: Assessment and plan short: Assessment and plan mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 51847-2, system: 'http://loinc.org'} index: 38 text: {short: text, mustSupport: true, index: 39} entry: index: 40 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: assessment_and_plan_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 41 required: [text, title, code] procedure_disposition_section: match: code: coding: - {code: 59775-7, system: 'http://loinc.org'} schema: label: Procedure Disposition Section short: Procedure Disposition Section mustSupport: true index: 104 elements: title: {short: title, mustSupport: true, index: 105} code: label: Procedure disposition short: Procedure disposition mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59775-7, system: 'http://loinc.org'} index: 106 text: {short: This section contains only human readable content, mustSupport: true, index: 107} required: [text, title, code] reason_for_visit_section: match: code: coding: - {code: 29299-5, system: 'http://loinc.org'} schema: label: Reason for Visit Section short: Reason for Visit Section mustSupport: true index: 130 elements: title: {short: title, mustSupport: true, index: 131} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29299-5, system: 'http://loinc.org'} index: 132 text: {short: This section contains only human readable content, mustSupport: true, index: 133} required: [text, title, code] past_medical_history_section: match: code: coding: - {code: 11348-0, system: 'http://loinc.org'} schema: label: Past Medical History Section short: Past Medical History Section mustSupport: true index: 62 elements: title: {short: title, mustSupport: true, index: 63} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11348-0, system: 'http://loinc.org'} index: 64 text: {short: text, mustSupport: true, index: 65} entry: short: entry index: 66 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: past_medical_history_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 67 required: [text, title, code] history_of_present_illness_section: match: code: coding: - {code: 10164-2, system: 'http://loinc.org'} schema: label: History of Present Illness Section short: History of Present Illness Section mustSupport: true index: 68 elements: title: {short: title, mustSupport: true, index: 69} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10164-2, system: 'http://loinc.org'} index: 70 text: {short: This section contains only human readable content, mustSupport: true, index: 71} required: [text, title, code] anesthesia_section: match: code: coding: - {code: 59774-0, system: 'http://loinc.org'} schema: label: Anesthesia Section short: Anesthesia Section mustSupport: true index: 42 elements: title: {short: title, mustSupport: true, index: 43} code: label: Anesthesia short: Anesthesia mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59774-0, system: 'http://loinc.org'} index: 44 text: {short: text, mustSupport: true, index: 45} entry: short: entry index: 46 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: anesthesia_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure'] index: 47 required: [text, title, code] medications_section: match: code: coding: - {code: 10160-0, system: 'http://loinc.org'} schema: label: Medications Section short: Medications Section mustSupport: true index: 76 elements: title: {short: title, mustSupport: true, index: 77} code: label: History of medication use short: History of medication use mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10160-0, system: 'http://loinc.org'} index: 78 text: {short: text, mustSupport: true, index: 79} entry: short: entry index: 80 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: medications_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest'] index: 81 required: [text, title, code] procedure_findings_section: match: code: coding: - {code: 59776-5, system: 'http://loinc.org'} schema: label: Procedure Findings Section short: Procedure Findings Section mustSupport: true index: 112 elements: title: {short: title, mustSupport: true, index: 113} code: label: Procedure findings short: Procedure findings mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59776-5, system: 'http://loinc.org'} index: 114 text: {short: This section contains only human readable content, mustSupport: true, index: 115} required: [text, title, code] social_history_section: match: code: coding: - {code: 29762-2, system: 'http://loinc.org'} schema: label: Social History Section short: Social History Section mustSupport: true index: 138 elements: title: {short: title, mustSupport: true, index: 139} code: label: Social history short: Social history mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29762-2, system: 'http://loinc.org'} index: 140 text: {short: text, mustSupport: true, index: 141} entry: short: entry index: 142 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: social_history_entry: match: {} schema: type: Reference short: Smoking status mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-smokingstatus'] index: 143 required: [text, title, code] procedures_section: match: code: coding: - {code: 47519-4, system: 'http://loinc.org'} schema: label: Procedures Section short: Procedures Section mustSupport: true index: 124 elements: title: {short: title, mustSupport: true, index: 125} code: label: History of procedures short: History of procedures mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 47519-4, system: 'http://loinc.org'} index: 126 text: {short: text, mustSupport: true, index: 127} entry: short: entry index: 128 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: procedures_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure'] index: 129 required: [text, title, code] chief_complaint_and_reason_for_visit_section: match: code: coding: - {code: 46239-0, system: 'http://loinc.org'} schema: label: Chief Complaint and Reason for Visit Section short: Chief Complaint and Reason for Visit Section. This section records the patient's chief complaint (the patient's own description) and/or the reason for the patient's visit (the provider's description of the reason for visit). Local policy determines whether the information is divided into two sections or recorded in one section serving both purposes. mustSupport: true index: 48 elements: title: {short: title, mustSupport: true, index: 49} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 46239-0, system: 'http://loinc.org'} index: 50 text: {short: This section contains only human readable content, mustSupport: true, index: 51} required: [text, title, code] procedure_estimated_blood_loss_section: match: code: coding: - {code: 59770-8, system: 'http://loinc.org'} schema: label: Procedure Estimated Blood Loss Section short: Procedure Estimated Blood Loss Section mustSupport: true index: 108 elements: title: {short: title, mustSupport: true, index: 109} code: label: Procedure estimated blood loss short: Procedure estimated blood loss mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59770-8, system: 'http://loinc.org'} index: 110 text: {short: This section contains only human readable content, mustSupport: true, index: 111} required: [text, title, code] plan_of_treatment_section: match: code: coding: - {code: 18776-5, system: 'http://loinc.org'} schema: label: Plan of Treatment Section short: Plan of Treatment Section mustSupport: true index: 94 elements: title: {short: title, mustSupport: true, index: 95} code: label: Plan of treatment short: Plan of treatment mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 18776-5, system: 'http://loinc.org'} index: 96 text: {short: text, mustSupport: true, index: 97} entry: short: entry index: 98 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: sliceEntry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. refers: ['http://hl7.org/fhir/StructureDefinition/Appointment', 'http://hl7.org/fhir/StructureDefinition/Communication', 'http://hl7.org/fhir/StructureDefinition/CommunicationRequest', 'http://hl7.org/fhir/StructureDefinition/DeviceRequest', 'http://hl7.org/fhir/StructureDefinition/NutritionOrder', 'http://hl7.org/fhir/StructureDefinition/RequestGroup', 'http://hl7.org/fhir/StructureDefinition/ServiceRequest', 'http://hl7.org/fhir/StructureDefinition/Task', 'http://hl7.org/fhir/StructureDefinition/VisionPrescription', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-goal', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest'] index: 99 required: [text, title, code] review_of_systems_section: match: code: coding: - {code: 10187-3, system: 'http://loinc.org'} schema: label: Review of Systems Section short: Review of Systems Section mustSupport: true index: 134 elements: title: {short: title, mustSupport: true, index: 135} code: label: Review of systems short: Review of systems mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10187-3, system: 'http://loinc.org'} index: 136 text: {short: This section contains only human readable content, mustSupport: true, index: 137} required: [text, title, code] physical_exam_section: match: code: coding: - {code: 29545-1, system: 'http://loinc.org'} schema: label: Physical Exam Section short: Physical Exam Section mustSupport: true index: 88 elements: title: {short: title, mustSupport: true, index: 89} code: label: Physical findings short: Physical findings mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29545-1, system: 'http://loinc.org'} index: 90 text: {short: text, mustSupport: true, index: 91} entry: short: entry index: 92 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: physical_exam_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/Observation'] index: 93 required: [text, title, code] procedure_indications_section: match: code: coding: - {code: 59768-2, system: 'http://loinc.org'} schema: label: Procedure Indications Section short: Procedure Indications Section mustSupport: true _required: true index: 16 elements: title: {short: title, mustSupport: true, index: 17} code: label: Procedure indications short: Procedure indications mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59768-2, system: 'http://loinc.org'} index: 18 text: {short: This section contains only human readable content, mustSupport: true, index: 19} required: [text, title, code] family_history_section: match: code: coding: - {code: 10157-6, system: 'http://loinc.org'} schema: label: Family History Section short: Family History Section mustSupport: true index: 56 elements: title: {short: title, mustSupport: true, index: 57} code: short: code mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 10157-6, system: 'http://loinc.org'} index: 58 text: {short: text, mustSupport: true, index: 59} entry: short: entry index: 60 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: family_history_entry: match: {} schema: type: Reference short: This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc. mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory'] index: 61 required: [text, title, code] medical_history_section: match: code: coding: - {code: 11329-0, system: 'http://loinc.org'} schema: label: Medical (General) History Section short: Medical (General) History Section mustSupport: true index: 72 elements: title: {short: title, mustSupport: true, index: 73} code: label: Medical (general) history short: Medical (general) history mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 11329-0, system: 'http://loinc.org'} index: 74 text: {short: This section contains only human readable content, mustSupport: true, index: 75} required: [text, title, code] procedure_specimens_taken_section: match: code: coding: - {code: 59773-2, system: 'http://loinc.org'} schema: label: Procedure Specimens Taken Section short: Procedure Specimens Taken Section mustSupport: true index: 120 elements: title: {short: title, mustSupport: true, index: 121} code: label: Procedure specimens taken short: Procedure specimens taken mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59773-2, system: 'http://loinc.org'} index: 122 text: {short: This section contains only human readable content, mustSupport: true, index: 123} required: [text, title, code] postprocedure_diagnosis_section: match: code: coding: - {code: 59769-0, system: 'http://loinc.org'} schema: label: Postprocedure Diagnosis Section short: Postprocedure Diagnosis Section mustSupport: true _required: true index: 20 elements: title: {short: title, mustSupport: true, index: 21} code: label: Postprocedure diagnosis short: Postprocedure diagnosis mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59769-0, system: 'http://loinc.org'} index: 22 text: {short: text, mustSupport: true, index: 23} entry: short: entry mustSupport: true index: 24 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: postprocedure_diagnosis_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition'] index: 25 required: [text, title, code] planned_procedure_section: match: code: coding: - {code: 59772-4, system: 'http://loinc.org'} schema: label: Planned Procedure Section short: Planned Procedure Section mustSupport: true index: 100 elements: title: {short: title, mustSupport: true, index: 101} code: label: Planned procedure short: Planned procedure mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59772-4, system: 'http://loinc.org'} index: 102 text: {short: text, mustSupport: true, index: 103} required: [text, title, code] medications_administered_section: match: code: coding: - {code: 29549-3, system: 'http://loinc.org'} schema: label: Medications Administered Section short: Medications Administered Section mustSupport: true index: 82 elements: title: {short: title, mustSupport: true, index: 83} code: label: Medications administered short: Medications administered mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 29549-3, system: 'http://loinc.org'} index: 84 text: {short: text, mustSupport: true, index: 85} entry: short: entry index: 86 slicing: rules: open discriminator: - {path: resolve(), type: profile} min: null slices: medications_administered_entry: match: {} schema: type: Reference mustSupport: true refers: ['http://hl7.org/fhir/StructureDefinition/MedicationStatement', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medication', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest'] index: 87 required: [text, title, code] procedure_implants_section: match: code: coding: - {code: 59771-6, system: 'http://loinc.org'} schema: label: Procedure Implants Section short: Procedure Implants Section mustSupport: true index: 116 elements: title: {short: title, mustSupport: true, index: 117} code: label: Procedure implants short: Procedure implants mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 59771-6, system: 'http://loinc.org'} index: 118 text: {short: This section contains only human readable content, mustSupport: true, index: 119} required: [text, title, code] assessment_section: match: code: coding: - {code: 51848-0, system: 'http://loinc.org'} schema: label: Assessment Section short: Assessment Section mustSupport: true index: 32 elements: title: {short: title, mustSupport: true, index: 33} code: label: Assessments short: Assessments mustSupport: true pattern: type: CodeableConcept value: coding: - {code: 51848-0, system: 'http://loinc.org'} index: 34 text: {short: This section contains only human readable content, mustSupport: true, index: 35} required: [text, title, code] package_version: 2.0.0-ballot class: profile kind: resource url: http://hl7.org/fhir/us/ccda/StructureDefinition/Procedure-Note base: http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header version: 2.0.0-ballot required: [event]