FHIR Server FHIR Server Version n/a

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The Operative Note recommends use of a single document type code, 11504-8 "Surgical 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.
Binding: SurgicalOperationNoteDocumentTypeCode
(required)
documentationOf
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DocumentationOf
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
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ServiceEvent
A serviceEvent represents the main act being documented, such as a colonoscopy or a cardiac stress study. In a provision of healthcare serviceEvent, the care providers, PCP, or other longitudinal providers, are recorded within the serviceEvent. If the document is about a single encounter, the providers associated can be recorded in the componentOf/encompassingEncounter template.
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Binding Description: (required) ⚠: The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (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 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).
Additional Bindings
Purpose
Documentation
Procedure
Preferred
Allowed SNOMED Codes
Constraints: 1198-8487
effectiveTime
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USRealmDateTimeInterval
Constraints: width-or-high
low
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IVXB_TS
Low is required
(Choice of one)
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width
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Represents the duration
high
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IVXB_TS
Equals low if only the date is known
Slices for performer
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Performer1
The performer participant represents clinicians who actually and principally carry out the serviceEvent. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patient's key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.
Slice: Unordered, Open by value:typeCode
performer:primary
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Performer1
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
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Fixed Value: PPRF
functionCode
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Binding: Care Team Member Function
(preferred)
assignedEntity
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AssignedEntity
Constraints: should-code
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Binding: Healthcare Provider Taxonomy
(required)
performer:secondary
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Performer1
This performer represents any assistants
@typeCode
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Fixed Value: SPRF
functionCode
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Binding: Care Team Member Function
(preferred)
assignedEntity
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AssignedEntity
Constraints: should-code
PreoperativeDiagnosisSection

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Binding: Healthcare Provider Taxonomy
(required)
authorization
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Authorization
Authorization represents consent. Consent, if present, shall be represented by authorization/consent.
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Slice: Unordered, Open by profile:section
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component:complications
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component:estBloodLoss
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ProcedureEstimatedBloodLossSection

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component:findings
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ProcedureFindingsSection
component:specimensTaken
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ProcedureSpecimensTakenSection

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component:procedureDescription
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ProcedureDescriptionSection

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component:postopDx
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PostoperativeDiagnosisSection

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component:implants
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ProcedureImplantsSection
component:fluids
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OperativeNoteFluidsSection

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component:surgicalProcedures
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OperativeNoteSurgicalProcedureSection

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component:planOfTreatment
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component:plannedProcedure

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PlanofTreatmentSection
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PlannedProcedureSection
component:disposition
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ProcedureDispositionSection

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component:indications
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ProcedureIndicationsSection

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component:surgicalDrains
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SurgicalDrainsSection
component:advDirectives
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