STU 1 Ballot

This page is part of the C-CDA on FHIR Implementation Guide (v1.6.0: STU 1 Ballot 1) based on FHIR v1.6.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

C-CDA on FHIR: ccda-operative-note-composition-example

Formats: XML Example or JSON Example or Turtle Example.

The narrative from the above example:

Operative Note

Operative Note document for Henry Jones

Managed by Community Health and Hospitals

Subject Details

Allergies and Intolerances Section

Substance Overall Severity Reaction Reaction Severity Status
Cashew Nut Severe Anaphylactic reaction Mild Active

Anesthesia Section

Conscious sedation with propofol 200 mg IV

Assessment Section

Obesity.

Uncontrolled brittle Type II diabetic.

Shortness of breath, mild wheezing.

Pressure ulder on left knee.

Assessment and Plan Section

Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy

Acute on chronic anemia secondary to #1.

Azotemia, acute renal failure with volume loss secondary tom#1.

Hyperkalemia secondary to #3 and on ACE and K+ supplement.

Other chronic diagnoses as noted above, currently stable.

Complications Section

Asthmatic symptoms while under general anesthesia.

Preoperative Diagnosis Section

Appendicitis

Operative Note Surgical Procedure Section

Laparoscopic Appendectomy

Planned Procedure Section

Colonoscopy

Procedure Indications Section

The procedure is performed for screening in a low risk individual.

Procedure Description Section

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.

Procedure Estimated Blood Loss Section

Minimal

Procedure Findings Section

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.

Procedure Specimens Taken Section

Ascending colon polyp

Operative Note Fluids Section

250 ML Ringers Lactate

Surgical Drains Section

Penrose drain placed

Procedure Implants Section

No implants were placed.

Procedure Disposition Section

The patient was taken to the Endoscopy Recovery Unit in stable condition.

Postoperative Diagnosis Section

Appendicitis with periappendiceal abscess

Plan of Treatment Section

Planned Activity Period Status
Colonoscopy 2010/08/16 - 2010/08/16 Completed
Recommendation to Exercise 2015/10/29 Ongoing

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.