abstractbaseDefinitioncopyrightdate- Values Differ
descriptionexperimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisherpurposestatustitletypeurlversion- Values Differ
| Left: | Operative Note (http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note) |
| Right: | Operative Note (http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note) |
| Error | StructureDefinition.version | Values for version differ: '1.1.0' vs '1.2.0-ballot' |
| Information | StructureDefinition.date | Values for date differ: '2020-10-21T22:01:58+00:00' vs '2023-03-27T20:45:24+00:00' |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/us/ccda/StructureDefinition/US-Realm-Header | ||
| copyright | |||
| date | 2020-10-21T22:01:58+00:00 | 2023-03-27T20:45:24+00:00 |
|
| description | The 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. | ||
| experimental | |||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | OperativeNote | ||
| publisher | HL7 Structured Documents Working Group | ||
| purpose | |||
| status | active | ||
| title | Operative Note | ||
| type | Composition | ||
| url | http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note | ||
| version | 1.1.0 | 1.2.0-ballot |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Composition | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | 0..* | USRealmHeader | A set of resources composed into a single coherent clinical statement with clinical attestation | |||||||||||
 id | Σ | 0..1 | string | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | S | 1..1 | code | language Binding: ?? (preferred): A human language.
| S | 1..1 | code | language Binding: ?? (preferred): A human language.
| |||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| identifier | SΣ | 1..1 | Identifier | identifier | SΣ | 1..1 | Identifier | identifier | |||||||||
| status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ?? (required): The workflow/clinical status of the composition. | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: ?? (required): The workflow/clinical status of the composition. | |||||||||
| type | SΣ | 1..1 | CodeableConcept | type Binding: ?? (required) | SΣ | 1..1 | CodeableConcept | type Binding: ?? (required) | |||||||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ?? (example): High-level kind of a clinical document at a macro level. | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ?? (example): High-level kind of a clinical document at a macro level. | |||||||||
| subject | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | SΣ | 0..1 | Reference(US Core Patient Profile | Group) | Who and/or what the composition is about | |||||||||
| encounter | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | SΣ | 0..1 | Reference(US Core Encounter Profile) | Context of the Composition | |||||||||
| date | SΣ | 1..1 | dateTime | date | SΣ | 1..1 | dateTime | date | |||||||||
| author | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | SΣ | 1..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | PractitionerRole | US Core Patient Profile | Device | RelatedPerson) | Who and/or what authored the composition | |||||||||
| title | SΣ | 1..1 | string | Document Title | SΣ | 1..1 | string | Document Title | |||||||||
| confidentiality | Σ | 0..0 | Σ | 0..0 | |||||||||||||
 Slices for attester | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| mode | 1..1 | code | personal | professional | legal | official Binding: ?? (required): The way in which a person authenticated a composition. | 1..1 | code | personal | professional | legal | official Binding: ?? (required): The way in which a person authenticated a composition. | |||||||||||
| time | 0..1 | dateTime | When the composition was attested | 0..1 | dateTime | When the composition was attested | |||||||||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||||||||
| custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | SΣ | 1..1 | Reference(US Core Organization Profile) | custodian | |||||||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | 0..* | BackboneElement | Relationships to other compositions/documents | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | |||||||||||
| target[x] | 1..1 | Identifier, Reference(Composition) | Target of the relationship | 1..1 | Identifier, Reference(Composition) | Target of the relationship | |||||||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | Σ | 0..* | BackboneElement | The clinical service(s) being documented | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. | |||||||||
| period | Σ | 0..1 | Period | The period covered by the documentation | Σ | 0..1 | Period | The period covered by the documentation | |||||||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | Σ | 0..* | Reference(Resource) | The event(s) being documented | |||||||||
 Slices for section | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | C | 0..* | BackboneElement | Composition is broken into sections Slice: Unordered, Open by value:code | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| title | 0..1 | string | Label for section (e.g. for ToC) | 0..1 | string | Label for section (e.g. for ToC) | |||||||||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: ?? (example): Classification of a section of a composition/document. | 0..1 | CodeableConcept | Classification of section (recommended) Binding: ?? (example): Classification of a section of a composition/document. | |||||||||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||||||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||||||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | C | 0..1 | Narrative | Text summary of the section, for human interpretation | |||||||||
| mode | 0..1 | code | working | snapshot | changes Binding: ?? (required): The processing mode that applies to this section. | 0..1 | code | working | snapshot | changes Binding: ?? (required): The processing mode that applies to this section. | |||||||||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ?? (preferred): What order applies to the items in the entry. | 0..1 | CodeableConcept | Order of section entries Binding: ?? (preferred): What order applies to the items in the entry. | |||||||||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | C | 0..* | Reference(Resource) | A reference to data that supports this section | |||||||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ?? (preferred): If a section is empty, why it is empty. | C | 0..1 | CodeableConcept | Why the section is empty Binding: ?? (preferred): If a section is empty, why it is empty. | |||||||||
 section | C | 0..* | See section | Nested Section | C | 0..* | See section (Composition) | Nested Section | |||||||||
| Documentation for this format | |||||||||||||||||