| Name | Flags | Card. | Type |
Description & Constraints
|
|---|---|---|---|---|
ClinicalDocument
|
USRealmHeaderV4 |
XML Namespace:
urn:hl7-org:v3 This logical model cannot be the target of a reference |
||
Slices for templateId
|
2 .. | Slice: Unordered, Open by value:root, value:extension | ||
templateId:secondary
|
1..1 | |||
root
|
1..1 | Required Pattern: 2.16.840.1.113883.10.20.22.1.7 | ||
extension
|
1..1 | Required Pattern: 2015-08-01 | ||
|
code
|
1..1 | The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. | ||
code
|
1..1 | Binding: SurgicalOperationNoteDocumentTypeCode ( required ) | ||
|
documentationOf
|
1..* |
A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements. |
||
|
serviceEvent
|
C | 1..1 | 1198-8487: The value of serviceEvent/code **SHALL** be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 *DYNAMIC* (CONF:1198-8487). | |
effectiveTime
|
C | 1..1 | http://hl7.org/cda/stds/core/StructureDefinition/IVL-TS |
1198-8488:
The serviceEvent/effectiveTime **SHALL** be present with effectiveTime/low (CONF:1198-8488). 1198-10058: If a width is not present, the serviceEvent/effectiveTime **SHALL** include effectiveTime/high (CONF:1198-10058). 1198-10060: When only the date and the length of the procedure are known a width element **SHALL** be present and the serviceEvent/effectiveTime/high **SHALL NOT** be present (CONF:1198-10060). |
|
Slices for performer
|
1 .. |
This performer represents any assistants.
Slice: Unordered, Open by value:assignedEntity, value:typeCode, value:functionCode |
||
performer:performer1
|
1..* |
This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. |
||
typeCode
|
1..1 | Fixed Value: PPRF | ||
|
functionCode
|
0..1 | Binding: Care Team Member Function ( preferred ) | ||
|
assignedEntity
|
1..1 | |||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( required ) | ||
|
performer:performer2
|
0..* | |||
|
typeCode
|
1..1 | Fixed Value: SPRF | ||
|
functionCode
|
0..1 | Binding: Care Team Member Function ( preferred ) | ||
|
assignedEntity
|
1..1 | |||
|
code
|
0..1 | Binding: Healthcare Provider Taxonomy ( required ) | ||
|
authorization
|
0..1 | Authorization represents consent. Consent, if present, shall be represented by authorization/consent. | ||
|
typeCode
|
1..1 | Fixed Value: AUTH | ||
|
consent
|
1..1 | |||
|
classCode
|
1..1 | Fixed Value: CONS | ||
|
moodCode
|
1..1 | Fixed Value: EVN | ||
|
statusCode
|
1..1 | |||
|
component
|
1..1 | |||
|
structuredBody
|
1..1 | |||
|
Slices for component
|
1 .. | Slice: Unordered, Open by value:ClinicalDocument.section | ||
|
component:component1
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component2
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component3
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component4
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component5
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component6
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component7
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component8
|
1..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component9
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component10
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component11
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component12
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component13
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component14
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component15
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
|
component:component16
|
0..1 | |||
|
section
|
1..1 | http://hl7.org/cda/stds/core/StructureDefinition/Section | ||
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Documentation for this format
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