StructureDefinition-Operative-Note

Sourcehl7.fhir.us.ccda#current:C-CDA on FHIR (v4.0.1)
resourceTypeStructureDefinition
idOperative-Note
canonicalhttp://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note
version1.2.0-ballot
statusactive
publisherHL7 Structured Documents Working Group
nameOperativeNote
titleOperative Note
date2023-03-27T20:25:00+00:00
descriptionThe Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeComposition
derivationconstraint
basehttp://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header
Usages
Name Flags Card. Type Description & Constraints doco
. . Composition USRealmHeader
. . . type S type
Binding: SurgicalOperationNoteDocumentTypeCode ( required )
. . . Slices for section Slice: Unordered, Open by value:code
. . . . section:anesthesia_section S 1..1 Anesthesia Section
. . . . . title S 1.. title
. . . . . code S 1.. Anesthesia
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59774-0
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:anesthesia_entry S Reference ( MedicationStatement | US Core Medication Profile | US Core MedicationRequest Profile | US Core Procedure Profile)
. . . . section:complications_section S 1..1 Complications Section
. . . . . title S 1.. title
. . . . . code S 1.. Complications
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 55109-3
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:complications_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:preoperative_diagnosis_section S 1..1 Preoperative Diagnosis Section
. . . . . title S 1.. title
. . . . . code S 1.. Preoperative Diagnosis
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10219-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:preoperative_diagnosis_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:procedure_estimated_blood_loss_section S 1..1 Procedure Estimated Blood Loss Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure Estimated Blood Loss
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59770-8
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_findings_section S 1..1 Procedure Findings Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure Findings
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59776-5
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:procedure_findings_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:procedure_specimens_taken_section S 1..1 Procedure Specimens Taken Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure Specimens Taken
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59773-2
. . . . . text S 1.. This section contains only human readable content
. . . . section:postoperative_diagnosis_section S 1..1 Postoperative Diagnosis Section
. . . . . title S 1.. title
. . . . . code S 1.. Postoperative Diagnosis
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10218-6
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_description_section S 1..1 Procedure Description Section
. . . . . title 1.. title
. . . . . code S 1.. Procedure Description
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 29554-3
. . . . . text S 1.. This section contains only human readable content
. . . . section:operative_note_surgical_procedure_section S ..1 Operative Note Surgical Procedure Section
. . . . . title S 1.. title
. . . . . code S 1.. Operative Note Surgical Procedure
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10223-6
. . . . . text S 1.. This section contains only human readable content
. . . . section:operative_note_fluids_section S ..1 Operative Note Fluids Section
. . . . . title S 1.. title
. . . . . code S 1.. Operative Note Fluids
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 10216-0
. . . . . text S 1.. This section contains only human readable content
. . . . section:plan_of_treatment_section S ..1 Plan of Treatment Section
. . . . . title S 1.. title
. . . . . code S 1.. Plan of Treatment
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18776-5
. . . . . text S 1.. text
. . . . . Slices for entry S entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:sliceEntry Reference (US Core Goal Profile | US Core MedicationRequest Profile | US Core Encounter Profile | Communication | Appointment | CommunicationRequest | DeviceRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:planned_procedure_section S ..1 Planned Procedure Section
. . . . . title S 1.. title
. . . . . code S 1.. Planned Procedure
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59772-4
. . . . . text S 1.. text
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:planned_procedure_entry S Reference ( ServiceRequest ) This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
. . . . section:procedure_disposition_section S ..1 Procedure Disposition Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure Disposition
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59775-7
. . . . . text S 1.. This section contains only human readable content
. . . . section:procedure_indications_section S ..1 Procedure Indications Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure Indications
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59768-2
. . . . . text S 1.. This section contains only human readable content
. . . . . Slices for entry entry
Slice: Unordered, Open by profile:resolve()
. . . . . . entry:problem_entry S Reference (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition)
. . . . section:procedure_implants_section S ..1 Procedure Implants Section
. . . . . title S 1.. title
. . . . . code S 1.. Procedure Implants
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 59771-6
. . . . . text S 1.. This section contains only human readable content
. . . . section:surgical_drains_section S ..1 Surgical Drains Section
. . . . . title S 1.. title
. . . . . code S 1.. Surgical Drains
Required Pattern: At least the following
. . . . . . coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
. . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: 11537-8
. . . . . text S 1.. This section contains only human readable content

doco Documentation for this format

Produced 06 Apr 2023