Encounter
Class ClinicalProcedureRecord

Clinical Procedures provided and or performed for the patient during the Encounter.

Attributes
«CS» Code bodySite bodySite

"Anatomical site where procedure is performed." For example, "Skin biopsy of the left eyelid." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

ComplicationEvent complication complication

An undesirable event experienced by a patient whilst undergoing a clinical procedure, especially if the event was caused by the procedure itself.

«TS» PointInTime dateTime dateTime

The date (and optionaly the time) that the professional service was performed.
"Date and time of procedure, may include duration." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

String description description

Textual description of the procedure.
"Narrative to further describe the procedure." For example, "A 6 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled. Moderate diverticulosis and hemorrhoids were incidentally noted." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

«CS» Code invasivenessOfProcedure invasivenessOfProcedure

"Describes invasiveness of the procedure." For example, Non-Invasive (ex: abdominal sonogram); Minimally Invasive (ex: endoscopy); Invasive (open surgery). - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

PractitionerParticipation performer performer
ServiceDeliveryLocation procedureFacility procedureFacility

Pointer to the location (e.g., the Facility) at which the Procedure was performed.

String procedureFindings procedureFindings

"Records clinically significant observations confirmed or discovered during the procedure or surgery." For example, "Necrotic left ovarian cyst was discovered and removed." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

String procedureImplants procedureImplants

"Records any materials placed during the procedure including stents, tubes, and drains." For example, "A doohickey pacemaker, number 3975359 was placed." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

ProcedureListEntry procedureList procedureList

Pointer to a list of Procedures (i.e., procedure codes) performed as part of the clinical procedure record.
"Contains a code indicating a procedure or a non-procedural event involving the patient. This code could come from various coding systems; typically the Common Procedure Terminology (CPT)". - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

RelatedProcedure relatedProcedure relatedProcedure
String specimensTaken specimensTaken

"Records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis." For example, "a .01x .02 cm biopsy was taken from the left ventricle." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

«CS» Code status status

A value specifying the state of this patient encounter (based on the RIM Act class state machine), for example, active, aborted, completed


Properties:

Alias
Classifier Behavior
Is Abstractfalse
Is Activefalse
Is Leaffalse
Keywords
NameClinicalProcedureRecord
Name Expression
NamespaceEncounter
Owned Template Signature
OwnerEncounter
Owning Template Parameter
PackageEncounter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord
Representation
Stereotype
Template Parameter
VisibilityPublic

Attribute Details

 bodySite
Public «CS» Code bodySite

"Anatomical site where procedure is performed." For example, "Skin biopsy of the left eyelid." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamebodySite
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::bodySite
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 complication
Public ComplicationEvent complication

An undesirable event experienced by a patient whilst undergoing a clinical procedure, especially if the event was caused by the procedure itself.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalProcedureRecord_complication
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
Namecomplication
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::complication
Stereotype
Template Parameter
TypeComplicationEvent
Upper*
Upper Value(*)
VisibilityPublic


 dateTime
Public «TS» PointInTime dateTime

The date (and optionaly the time) that the professional service was performed.
"Date and time of procedure, may include duration." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
NamedateTime
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::dateTime
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 description
Public String description

Textual description of the procedure.
"Narrative to further describe the procedure." For example, "A 6 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled. Moderate diverticulosis and hemorrhoids were incidentally noted." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Namedescription
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::description
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 invasivenessOfProcedure
Public «CS» Code invasivenessOfProcedure

"Describes invasiveness of the procedure." For example, Non-Invasive (ex: abdominal sonogram); Minimally Invasive (ex: endoscopy); Invasive (open surgery). - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameinvasivenessOfProcedure
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::invasivenessOfProcedure
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 performer
Public PractitionerParticipation performer
Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Nameperformer
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::performer
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 procedureFacility
Public ServiceDeliveryLocation procedureFacility

Pointer to the location (e.g., the Facility) at which the Procedure was performed.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameprocedureFacility
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::procedureFacility
Stereotype
Template Parameter
TypeServiceDeliveryLocation
Upper1
Upper Value(1)
VisibilityPublic


 procedureFindings
Public String procedureFindings

"Records clinically significant observations confirmed or discovered during the procedure or surgery." For example, "Necrotic left ovarian cyst was discovered and removed." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameprocedureFindings
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::procedureFindings
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 procedureImplants
Public String procedureImplants

"Records any materials placed during the procedure including stents, tubes, and drains." For example, "A doohickey pacemaker, number 3975359 was placed." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameprocedureImplants
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::procedureImplants
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 procedureList
Public ProcedureListEntry procedureList

Pointer to a list of Procedures (i.e., procedure codes) performed as part of the clinical procedure record.
"Contains a code indicating a procedure or a non-procedural event involving the patient. This code could come from various coding systems; typically the Common Procedure Terminology (CPT)". - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalProcedureRecord_procedureList
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameprocedureList
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::procedureList
Stereotype
Template Parameter
TypeProcedureListEntry
Upper*
Upper Value(*)
VisibilityPublic


 relatedProcedure
Public RelatedProcedure relatedProcedure
Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalProcedureRecord_relatedProcedure
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamerelatedProcedure
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::relatedProcedure
Stereotype
Template Parameter
TypeRelatedProcedure
Upper*
Upper Value(*)
VisibilityPublic


 specimensTaken
Public String specimensTaken

"Records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis." For example, "a .01x .02 cm biopsy was taken from the left ventricle." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamespecimensTaken
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::specimensTaken
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 status
Public «CS» Code status

A value specifying the state of this patient encounter (based on the RIM Act class state machine), for example, active, aborted, completed

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalProcedureRecord
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Namestatus
Name Expression
NamespaceClinicalProcedureRecord
Opposite
OwnerClinicalProcedureRecord
Owning Association
Owning Template Parameter
Qualified NameFHIM::Encounter::ClinicalProcedureRecord::status
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic