FHIR IG analytics| Package | hl7.fhir.us.ccda.r4 |
| Resource Type | Composition |
| Id | Composition-Operative-Note-Example.json |
| FHIR Version | R4 |
No resources found
No resources found
Note: links and images are rebased to the (stated) source
| Document Id | 12345 |
| Document Created: | June 15, 2016, 16:14, PST |
| Care Provision | Operation Note for Amy Shaw |
| Performer | Ronald Boone, MD |
| Author | Ronald Boone, MD |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
| Encounter Id | 9937012 2.16.840.1.113883.19 |
| Event Type | Surgery |
| Event Date | From June 15, 2016, 16:20 to June 15, 2016, 18:20 |
| Encounter Location | Perioperative Department at Community Health and Hospitals |
| Responsible party | Ronald Boone, MD |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
| Assigned entity | Community Health and Hospitals
|
| Emergency contact | Michael Shaw
|
| Contact info | 49 Meadow St
Amherst MA 01003, US Tel: (555)555-1212 |
| Care giver | Mrs. Lillian White
|
| Contact info | 49 Meadow St
Amherst MA 01003, US Tel: (555)555-1215 |
| Entered by | Sally Jones |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
| Signed | Ronald Boone at June 15, 2016 |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
| Informant | Henry Vincent, CPh |
| Contact info | 1007 Pharmacy Drive
Portland, OR 99123, US Tel: +1(555)555-1215 |
| Information recipient: | Primary Physician, MD |
| Contact info | 1005 St. Clair Avenue
Amherst MA 01002, US Tel: +1(555)555-1666 |
| Legal authenticator | Ronald Boone, MD signed at June 15, 2016 |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
| Document maintained by | Community Health and Hospitals |
| Contact info | 1003 Healthcare Drive
Amherst MA 01002, US Tel: +1(555)555-1003 |
FHIR
FHIRsmith{
"resourceType": "Composition",
"id": "Operative-Note-Example",
"meta": {
"versionId": "4",
"lastUpdated": "2020-08-12T21:30:19.501+00:00",
"source": "#csn482LCsnDWyxbW",
"profile": [
"http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note"
]
},
"language": "en-US",
"text": {
"status": "generated",
"div": "<!-- snip (see above) -->"
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:uuid:75a12dcd-f85d-4c7f-b1de-38a1a2b7498f"
},
"status": "preliminary",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "11504-8",
"display": "Surgical operation note"
}
]
},
"subject": {
"reference": "Patient/example",
"display": "Amy V. Shaw"
},
"date": "2016-06-15T09:10:14Z",
"author": [
{
"reference": "PractitionerRole/ccda-practitionerrole-example",
"display": "Ronald Bone, MD"
}
],
"title": "Operative Note",
"attester": [
{
"mode": "legal",
"time": "2016-06-15T09:10:14Z",
"party": {
"reference": "PractitionerRole/ccda-practitionerrole-example",
"display": "Ronald Boone, MD"
}
}
],
"custodian": {
"reference": "Organization/organization-1",
"display": "Community Health and Hospitals"
},
"event": [
{
"code": [
{
"coding": [
{
"system": "http://snomed.info/sct",
"code": "73761001",
"display": "Colonoscopy"
}
]
}
],
"period": {
"start": "2016-06-15",
"end": "2016-06-15"
}
}
],
"section": [
{
"title": "Anesthesia Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59774-0",
"display": "Anesthesia"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Conscious sedation with propofol 200 mg IV</p>\n </div>"
}
},
{
"title": "Complications Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "55109-3",
"display": "Complications Document"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Asthmatic symptoms while under general anesthesia.</p>\n </div>"
},
"entry": [
{
"reference": "Condition/condition-problem"
}
]
},
{
"title": "Preoperative Diagnosis Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10219-4",
"display": "Surgical operation note preoperative diagnosis Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis</p>\n </div>"
}
},
{
"title": "Operative Note Surgical Procedure Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10223-6",
"display": "Surgical operation note surgical procedure Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Laparoscopic Appendectomy</p>\n </div>"
}
},
{
"title": "Planned Procedure Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59772-4",
"display": "Planned procedure"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Colonoscopy</p>\n </div>"
}
},
{
"title": "Procedure Indications Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59768-2",
"display": "Procedure indications [Interpretation] Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The procedure is performed for screening in a low risk\n individual.</p>\n </div>"
}
},
{
"title": "Procedure Description Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "29554-3",
"display": "Procedure Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was brought to the operating room, placed in the supine\n position, and general anesthesia was induced. A detailed technical\n narrative of a laparoscopic appendectomy from initial incision to\n placement of any dressings follows. </p>\n </div>"
}
},
{
"title": "Procedure Estimated Blood Loss Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59770-8",
"display": "Procedure estimated blood loss Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Minimal</p>\n </div>"
}
},
{
"title": "Procedure Findings Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59776-5",
"display": "Procedure findings Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>A 6 mm sessile polyp was found in the ascending colon and removed by\n snare, no cautery. Bleeding was controlled. Moderate diverticulosis\n and hemorrhoids were incidentally noted.</p>\n </div>"
},
"entry": [
{
"reference": "Condition/condition-problem"
}
]
},
{
"title": "Procedure Specimens Taken Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59773-2",
"display": "Procedure specimens taken Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Ascending colon polyp</p>\n </div>"
}
},
{
"title": "Operative Note Fluids Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10216-0",
"display": "Operative Note Fluids"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>250 ML Ringers Lactate</p>\n </div>"
}
},
{
"title": "Surgical Drains Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "11537-8",
"display": "Surgical Drains"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Penrose drain placed</p>\n </div>"
}
},
{
"title": "Procedure Implants Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59771-6",
"display": "Procedure implants Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>No implants were placed.</p>\n </div>"
}
},
{
"title": "Procedure Disposition Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "59775-7",
"display": "Procedure disposition Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>The patient was taken to the Endoscopy Recovery Unit in stable\n condition.</p>\n </div>"
}
},
{
"title": "Postoperative Diagnosis Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "10218-6",
"display": "Surgical operation note postoperative diagnosis Narrative"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p>Appendicitis with periappendiceal abscess</p>\n </div>"
}
},
{
"title": "Plan of Treatment Section",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "18776-5",
"display": "Plan of care note"
}
]
},
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <table>\n <tr>\n <td>\n <b>Planned Activity</b>\n </td>\n <td>\n <b>Period</b>\n </td>\n <td>\n <b>Status</b>\n </td>\n </tr>\n <tr>\n <td>Colonoscopy</td>\n <td>2016/09/17 - 2010/09/17</td>\n <td>Planned</td>\n </tr>\n <tr>\n <td>Recommendation to Exercise</td>\n <td>2016/06/25</td>\n <td>Ongoing</td>\n </tr>\n </table>\n </div>"
}
}
]
}