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Narrative

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Source1

{
  "resourceType": "Procedure",
  "id": "opProzedur-00",
  "meta": {
    "profile": [
      "http://fhir.dguv.de/OPER/Procedure/DGUV-OPER-PR-OPProzedur"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Narkose",
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-Narkose",
            "code": "LA",
            "display": "Lokalanästhesie"
          }
        ],
        "text": "Drei Tropfen auf die Haut"
      }
    },
    {
      "url": "http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Schnittzeit",
      "valueDateTime": "2026-02-25T09:15:00+01:00"
    },
    {
      "url": "http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Nahtzeit",
      "valueDateTime": "2026-02-25T10:05:00+01:00"
    },
    {
      "url": "http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-OPBefundVerlauf",
      "valueString": "Intraoperativer Befund: Krank. Keine Komplikationen. Verlauf regelrecht."
    }
  ],
  "status": "completed",
  "code": {
    "coding": [
      {
        "extension": [
          {
            "url": "http://fhir.de/StructureDefinition/seitenlokalisation",
            "valueCoding": {
              "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION",
              "code": "R",
              "display": "rechts"
            }
          }
        ],
        "system": "http://fhir.de/CodeSystem/bfarm/ops",
        "code": "5-470",
        "display": "Appendektomie"
      },
      {
        "system": "http://snomed.info/sct",
        "code": "80146002",
        "display": "Appendectomy"
      }
    ],
    "text": "Exzision des Wurmfortsatzes"
  },
  "subject": {
    "reference": "urn:uuid:482bb42d-a37b-45f7-8893-0abe669bd8ba"
  },
  "encounter": {
    "identifier": {
      "value": "FALL-2026-000123"
    }
  },
  "performedDateTime": "2026-02-25",
  "reasonCode": [
    {
      "text": "Starke Schmerzen im rechten Unterbauch. Wurmfortsatz stark entzündet."
    }
  ],
  "bodySite": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "66754008",
          "display": "Appendix structure (body structure)"
        }
      ],
      "text": "Appendix"
    }
  ],
  "followUp": [
    {
      "text": "Teilbelastung für 6 Wochen, anschließend schrittweiser Belastungsaufbau."
    }
  ],
  "focalDevice": [
    {
      "manipulated": {
        "extension": [
          {
            "url": "http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Seitenlokalisation",
            "valueCoding": {
              "system": "http://snomed.info/sct",
              "code": "24028007",
              "display": "Right"
            }
          }
        ],
        "reference": "urn:uuid:implantat-001"
      }
    }
  ]
}