9.8.2 Procedure Indications

9.8.2 Procedure Indications (Current)
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Template ID	2.16.840.1.113883.10.20.22.2.29
Name	Procedure Indications
Effective Date	2012-07
Version Label	DICOM-20150324
Status	Active
Description	Records details about the reason for the procedure. This section may include the pre-procedure diagnosis or diagnoses as well as one or more symptoms that contribute to the reason the procedure is being performed.
Classification	CDA Section Level
Relationships	Included in 9.2 Clinical Information
Context	parent node
Open/Closed	Open
Revision History	From Consolidated CDA r1.1 DICOM-20150324: adapted to use optional Coded Observation entry rather than optional Indication entry

Business Name	Nest Level	Element/Attribute	Card	Elem/Attr Conf	Data Type	Value Conf	Value	Subsidiary Template
ProcedureIndications		section	1..1	SHALL
	>	templateId	1..1	SHALL	II
	>@	@root	1..1	SHALL	UID	SHALL	2.16.840.1.113883.10.20.22.2.29
	>	id	1..*	SHALL	II
	>	code	1..1	SHALL	CD	SHALL	(59768-2, LOINC, "Procedure Indications")
Title	>	title	1..1	SHALL	ST
Text	>	text	1..1	COND	ED			9.1.1 Section Text 1.2.840.10008.9.19
	>	entry	0..*	MAY
CodedObservation[*]	>>	observation	1..1	SHALL			See 9.8.2.1 entry/observation	10.1 Coded Observation 2.16.840.1.113883.10.20.6.2.13

9.8.2.1 entry/observation

The binding to the Coded Observation concept domains is:

Concept Domain or Element	Value Conf	Value
ObservationType	SHOULD	(432678004, SNOMED, "Indication for procedure")
Other concept domains		unspecified

Note

In Consolidated CDA r1.1 the binding to the observationType is to Value Set Problem Type (2.16.840.1.113883.3.88.12.3221.7.2) with conformance SHOULD. Values from that Value Set are acceptable here as well.

Example 9.8.2.1-1. Procedure indications section example

<section classCode="DOCSECT" moodCode="EVN">
    <templateId root="2.16.840.1.113883.10.20.22.2.29"/>
    <id root="1.2.840.10213.2.62.044785528.1142895426"/>
    <code code="59768-2"
        codeSystem="2.16.840.1.113883.6.1"
        codeSystemName="LOINC"
        displayName="Procedure Indications"/>
    <title>Procedure Indications</title>
    <text>The procedure is performed as a follow-up for abnormal screening result.</text>
</section>

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9.8 Sub-sections	Home	9.8.3 Medical (General) History