The Planned Procedure form element allows healthcare providers to document planned procedures in a structured format that maintains SNOMED codification. This feature is part of the ONC HTI-1 certification updates to support USCDI v3 Health Status Assessments.
Overview | Adding a Planned Procedure | Search & Select a Planned Procedure | Auto-Populate Code Attachment | Customize Note Section | Documenting | CCDA Output
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Overview
The Planned Procedure element enables providers to:
- Document upcoming or scheduled procedures
- Capture procedure information in a standardized format
- Ensure SNOMED-based codification for interoperability
- Include planned procedure data in CCDA exports
Adding Planned Procedure in Clinical Form Management
Steps to Add the Element
- Navigate to Clinical Form Management
- Open or create a form
- Select Clinical Field from the form elements
- Choose Planned Procedure as the observation type
- Configure the procedure parameters
Search & Select a Planned Procedure
A single-select search field labeled "Procedure" enables users to search for planned procedures.
Supported Value Sets
Users can search for a planned procedure within the following coding systems:
- LOINC - Logical Observation Identifiers Names and Codes
- SNOMED - Systematized Nomenclature of Medicine
- CPT - Current Procedural Terminology
- ICD-10 - International Classification of Diseases
- HCPCS - Healthcare Common Procedure Coding System
- Social Determinant of Health value set - SDOH-related procedures and services
Search Results Include:
- Procedure Name (description) - The descriptive name of the procedure
- SNOMED code - The standardized SNOMED identifier
Auto-Populate Code Attachment
Upon selecting a procedure, the system automatically handles code attachment:
Automatic Population
- The SNOMED code is automatically populated in the Code attachment section
- This code is not editable to maintain data integrity
Manual Code Addition
Users can add other associated codes manually, including:
- CPT codes
- HCPCS codes
- ICD-10 codes
- Custom codes
SNOMED codes remain automatically populated and cannot be edited.
Customize Note Section
The Customized Note section maintains its current functionality:
- Editable by the user
- Allows customization of how the planned procedure appears in documentation
- Supports practice-specific documentation preferences
Documenting Planned Procedure in Clinical Note
Steps to Document
- Add the Planned Procedure form to the Clinical note
- Use the date picker field to enter the planned date or relevant timeframe
- Complete any additional required fields
The date picker allows you to specify when the procedure is scheduled or expected to occur.
CCDA Output
The planned procedure data is properly formatted for CCDA export:
Compliance Mapping
- Displayed correctly in the CCDA PDF generator
- Maps back to Planned Procedure Narrative LOINC Value: LOINC 59772-4
- Ensures interoperability with other healthcare systems
- Supports continuity of care and care coordination
Data Structure
The data follows HL7 standards for planned procedures, ensuring:
- Proper XML structure in CCDA documents
- Compatibility with receiving systems
- Accurate representation of planned care activities