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Packagefhir.ph.core
Resource TypeProcedure
IdProcedure-procedure-single-example.json
FHIR VersionR4

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Narrative

Note: links and images are rebased to the (stated) source

Procedure: Laparoscopic appendectomy (SNOMED CT: 80146002)

Subject: Juan Dela Cruz

Status: Completed

Performed: January 15, 2024, 08:30 - 10:15 (Asia/Manila)

Performer: Dr. Maria Clara Santos (Healthcare professional) on behalf of Department of Health - Central Office

Reason: Acute appendicitis with peritonitis (SNOMED CT: 74400008)

Body Site: Entire appendix - Right lower quadrant abdomen

Outcome: Successful - Procedure completed without complications

Follow-up: Postsurgical wound care in 7 days

Notes: Patient tolerated procedure well. Minimal blood loss. Appendix was inflamed but intact.


Source1

{
  "resourceType": "Procedure",
  "id": "procedure-single-example",
  "meta": {
    "profile": [
      "http://doh.gov.ph/fhir/ph-core/StructureDefinition/ph-core-procedure"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "identifier": [
    {
      "use": "usual",
      "system": "http://doh.gov.ph/fhir/ph-core/NamingSystem/procedure-id",
      "value": "PROC-2024-000123"
    },
    {
      "use": "secondary",
      "system": "http://philhealth.gov.ph/procedure",
      "value": "PH-APP-789456"
    }
  ],
  "basedOn": [
    {
      "display": "ServiceRequest for emergency appendectomy"
    }
  ],
  "partOf": [
    {
      "display": "Episode of care for acute abdomen treatment"
    }
  ],
  "status": "completed",
  "statusReason": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "385669000",
        "display": "Successful"
      }
    ]
  },
  "category": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "387713003",
        "display": "Surgical procedure"
      }
    ]
  },
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "80146002",
        "display": "Appendectomy"
      }
    ],
    "text": "Laparoscopic appendectomy"
  },
  "subject": {
    "reference": "Patient/patient-single-example"
  },
  "encounter": {
    "reference": "Encounter/encounter-single-example"
  },
  "performedPeriod": {
    "start": "2024-01-15T08:30:00+08:00",
    "end": "2024-01-15T10:15:00+08:00"
  },
  "recorder": {
    "reference": "Practitioner/practitioner-single-example"
  },
  "asserter": {
    "reference": "RelatedPerson/relatedperson-single-example"
  },
  "performer": [
    {
      "function": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "223366009",
            "display": "Healthcare professional"
          }
        ]
      },
      "actor": {
        "reference": "Practitioner/practitioner-single-example"
      },
      "onBehalfOf": {
        "reference": "Organization/organization-single-example"
      }
    },
    {
      "function": {
        "coding": [
          {
            "system": "http://snomed.info/sct",
            "code": "133932002",
            "display": "Caregiver"
          }
        ]
      },
      "actor": {
        "reference": "RelatedPerson/relatedperson-single-example"
      }
    }
  ],
  "reasonCode": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "74400008",
          "display": "Appendicitis"
        }
      ],
      "text": "Acute appendicitis with peritonitis"
    }
  ],
  "reasonReference": [
    {
      "reference": "Condition/condition-single-example"
    }
  ],
  "bodySite": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "66754008",
          "display": "Appendix structure"
        }
      ],
      "text": "Right lower quadrant abdomen"
    }
  ],
  "outcome": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "385669000",
        "display": "Successful"
      }
    ],
    "text": "Procedure completed without complications"
  },
  "followUp": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "226007004",
          "display": "Post-surgical wound care"
        }
      ],
      "text": "Follow-up visit in 7 days for wound check"
    }
  ],
  "note": [
    {
      "time": "2024-01-15T10:30:00+08:00",
      "text": "Patient tolerated procedure well. Minimal blood loss. Appendix was inflamed but intact. No perforation noted."
    }
  ],
  "usedCode": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "261424001",
          "display": "Primary operation"
        }
      ],
      "text": "Laparoscopic instruments"
    }
  ]
}