This page is part of the C-CDA on FHIR Implementation Guide (v1.0.0: STU 1) based on FHIR R3. This is the current published version. For a full list of available versions, see the Directory of published versions
<Composition xmlns="http://hl7.org/fhir"> <id value="CCDA-on-FHIR-Operative-Note-Example"/> <meta> <versionId value="1"/> <lastUpdated value="2016-06-15T08:16:14Z"/> <profile value="http://hl7.org/fhir/us/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note"/> </meta> <language value="en-US"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Document Id</span> </td> <td class="td_header_role_value">12345</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Document Created:</span> </td> <td class="td_header_role_value">June 15, 2016, 16:14, PST </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Care Provision</span> </td> <td class="td_header_role_value">Operation Note for Amy Shaw</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Performer </span> </td> <td class="td_header_role_value">Ronald Boone, MD</td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Author</span> </td> <td class="td_header_role_value">Ronald Boone, MD</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Encounter Id</span> </td> <td class="td_header_role_value">9937012 2.16.840.1.113883.19</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Event Type</span> </td> <td class="td_header_role_value">Surgery</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Event Date</span> </td> <td class="td_header_role_value"> From June 15, 2016, 16:20 to June 15, 2016, 18:20 </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Encounter Location</span> </td> <td class="td_header_role_value">Perioperative Department at Community Health and Hospitals</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Responsible party</span> </td> <td class="td_header_role_value">Ronald Boone, MD</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Assigned entity</span> </td> <td class="td_header_role_value">Community Health and Hospitals<br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Emergency contact</span> </td> <td class="td_header_role_value">Michael Shaw<br/> <br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">49 Meadow St<br/>Amherst MA 01003, US<br/>Tel: (555)555-1212<br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Care giver</span> </td> <td class="td_header_role_value">Mrs. Lillian White<br/> </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">49 Meadow St<br/>Amherst MA 01003, US<br/>Tel: (555)555-1215<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Entered by</span> </td> <td class="td_header_role_value">Sally Jones</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Signed </span> </td> <td class="td_header_role_value">Ronald Boone at June 15, 2016 </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Informant</span> </td> <td class="td_header_role_value">Henry Vincent, CPh</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1007 Pharmacy Drive<br/>Portland, OR 99123, US<br/>Tel: +1(555)555-1215<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Information recipient:</span> </td> <td class="td_header_role_value">Primary Physician, MD</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1005 St. Clair Avenue<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1666<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Legal authenticator</span> </td> <td class="td_header_role_value">Ronald Boone, MD signed at June 15, 2016 </td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> <table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table"> <tbody> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Document maintained by</span> </td> <td class="td_header_role_value">Community Health and Hospitals</td> </tr> <tr> <td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name"> <span class="td_label">Contact info</span> </td> <td class="td_header_role_value">1003 Healthcare Drive<br/>Amherst MA 01002, US<br/>Tel: +1(555)555-1003<br/> </td> </tr> </tbody> </table> </div> </text> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="1"/> </identifier> <status value="preliminary"/> <type> <coding> <system value="http://loinc.org"/> <code value="11504-8"/> <display value="Provider-unspecified Operation Note"/> </coding> </type> <!-- Patient Resource --> <subject> <reference value="Patient/patient-1"/> <display value="Amy V. Shaw"/> </subject> <date value="2016-06-15T09:10:14Z"/> <!-- Practitioner Resource --> <author> <reference value="Practitioner/practitioner-1"/> <display value="Ronald Boone, MD"/> </author> <title value="Operative Note"/> <confidentiality value="N"/> <attester> <mode value="legal"/> <time value="2016-06-15T09:10:14Z"/> <party> <reference value="Practitioner/practitioner-1"/> <display value="Ronald Boone, MD"/> </party> </attester> <!-- Organization Resource --> <custodian> <reference value="Organization/organization-1"/> <display value="Community Health and Hospitals"/> </custodian> <event> <code> <coding> <system value="http://snomed.info/sct"/> <code value="73761001"/> <display value="Colonoscopy"/> </coding> </code> <period> <start value="2016-06-15"/> <end value="2016-06-15"/> </period> </event> <!-- Encounter Resource --> <!-- <encounter><reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/></encounter> --> <!-- Allergies and Intolerances Section Narrative --> <section> <title value="Allergies and Intolerances Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="48765-2"/> <display value="Allergies and adverse reactions"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Substance</b> </td> <td> <b>Overall Severity</b> </td> <td> <b>Reaction</b> </td> <td> <b>Reaction Severity</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Cashew Nut</td> <td>Severe</td> <td>Anaphylactic reaction</td> <td>Mild</td> <td>Active</td> </tr> </table> </div> </text> <mode value="snapshot"/> <orderedBy> <coding> <system value="http://hl7.org/fhir/list-order"/> <code value="event-date"/> <display value="Sorted by Event Date"/> </coding> </orderedBy> <!-- Allergies and Intolerances Section Resource --> <entry> <reference value="AllergyIntolerance/allergy-intolerance"/> </entry> </section> <!-- Anesthesia Section Narrative --> <section> <title value="Anesthesia Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59774-0"/> <display value="Anesthesia"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Conscious sedation with propofol 200 mg IV</p> </div> </text> <!-- Anesthesia Section Condition Resource --> <entry> <reference value="Condition/condition-problem"/> </entry> </section> <!-- Assessment Section Narrative --> <section> <title value="Assessment Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="51848-0"/> <display value="Assessment (evaluation)"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Obesity.</p> <p>Uncontrolled brittle Type II diabetic.</p> <p>Shortness of breath, mild wheezing.</p> <p>Pressure ulder on left knee.</p> </div> </text> </section> <!-- Assessment and Plan Section Narrative --> <section> <title value="Assessment and Plan Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="51847-2"/> <display value="Assessment (evaluation) and plan"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy</p> <p>Acute on chronic anemia secondary to #1.</p> <p>Azotemia, acute renal failure with volume loss secondary tom#1.</p> <p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p> <p>Other chronic diagnoses as noted above, currently stable.</p> </div> </text> </section> <!-- Complications Section Narrative --> <section> <title value="Complications Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="55109-3"/> <display value="Complications"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Asthmatic symptoms while under general anesthesia.</p> </div> </text> <!-- Complications Section Condition Resource --> <entry> <reference value="Condition/condition-problem"/> </entry> </section> <!-- Preoperative Diagnosis Section Narrative --> <section> <title value="Preoperative Diagnosis Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10219-4"/> <display value="Preoperative Diagnosis"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Appendicitis</p> </div> </text> </section> <!-- Surgical Procedure Section Narrative --> <section> <title value="Operative Note Surgical Procedure Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10223-6"/> <display value="Operative Note Surgical Procedure"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Laparoscopic Appendectomy</p> </div> </text> </section> <!-- Planned Procedure Section Narrative --> <section> <title value="Planned Procedure Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59772-4"/> <display value="Planned procedure"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Colonoscopy</p> </div> </text> </section> <!-- Procedure Indications Section Narrative --> <section> <title value="Procedure Indications Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59768-2"/> <display value="Procedure indications"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>The procedure is performed for screening in a low risk individual.</p> </div> </text> </section> <!-- Procedure Description Section Narrative --> <section> <title value="Procedure Description Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="29554-3"/> <display value="Procedure description"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>The patient was brought to the operating room, placed in the supine position, and general anesthesia was induced. A detailed technical narrative of a laparoscopic appendectomy from initial incision to placement of any dressings follows. </p> </div> </text> </section> <!-- Procedure Estimated Blood Loss Section Narrative --> <section> <title value="Procedure Estimated Blood Loss Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59770-8"/> <display value="Procedure Estimated Blood Loss"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Minimal</p> </div> </text> </section> <!-- Procedure Findings Section Narrative --> <section> <title value="Procedure Findings Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59776-5"/> <display value="Procedure findings"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>A 6 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled. Moderate diverticulosis and hemorrhoids were incidentally noted.</p> </div> </text> <!-- Procedure Findings Section Condition Resource --> <entry> <reference value="Condition/condition-problem"/> </entry> </section> <!-- Procedure Specimens Taken Section Narrative --> <section> <title value="Procedure Specimens Taken Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59773-2"/> <display value="Procedure specimens taken"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Ascending colon polyp</p> </div> </text> </section> <!-- Operative Note Fluids Section Narrative --> <section> <title value="Operative Note Fluids Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10216-0"/> <display value="Operative Note Fluids"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>250 ML Ringers Lactate</p> </div> </text> </section> <!-- Surgical Drains Section Narrative --> <section> <title value="Surgical Drains Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="11537-8"/> <display value="Surgical Drains"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Penrose drain placed</p> </div> </text> </section> <!-- Procedure Implants Section Narrative --> <section> <title value="Procedure Implants Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59771-6"/> <display value="Procedure implants"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>No implants were placed.</p> </div> </text> </section> <!-- Procedure Disposition Section Narrative --> <section> <title value="Procedure Disposition Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="59775-7"/> <display value="Procedure disposition"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>The patient was taken to the Endoscopy Recovery Unit in stable condition.</p> </div> </text> </section> <!-- Preoperative Diagnosis Section Narrative --> <section> <title value="Postoperative Diagnosis Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="10218-6"/> <display value="Postoperative Diagnosis"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <p>Appendicitis with periappendiceal abscess</p> </div> </text> </section> <!-- Plan of Treatment Section Narrative --> <section> <title value="Plan of Treatment Section"/> <code> <coding> <system value="http://loinc.org"/> <code value="18776-5"/> <display value="Plan of treatment"/> </coding> </code> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"> <table> <tr> <td> <b>Planned Activity</b> </td> <td> <b>Period</b> </td> <td> <b>Status</b> </td> </tr> <tr> <td>Colonoscopy</td> <td>2016/09/17 - 2010/09/17</td> <td>Planned</td> </tr> <tr> <td>Recommendation to Exercise</td> <td>2016/06/25</td> <td>Ongoing</td> </tr> </table> </div> </text> </section> </Composition>