An activity that is performed with or on a patient as part of the provision of care.

Data Element

Additional Information

Procedures

Applicable Vocabulary Standard(s)

Applicable Standards
  • SNOMED International, Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) U.S. Edition, March 2021 Release
  • Current Procedural Terminology (CPT®) 2021, as maintained and distributed by the American Medical Association, for physician services and other health care services, and Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by HHS.
  • For technology primarily developed to record dental procedures: Code on Dental Procedures and Nomenclature (CDT), maintained and distributed by the American Dental Association, for dental services.
Optional:
  • International Classification of Diseases ICD-10-PCS 2021

Comment

Rename for specificity

To delineate the element name from the class name, MedMorph suggests renaming the Procedures element to Procedure Code. This modification will more closely align with the USCDI definition of a Data Element ("A USCDI “Data Element” is the most granular level at which a piece of data is exchanged") as well as with US Core.

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