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

{
  "resourceType" : "Composition",
  "id" : "ccda-operative-note-composition-example",
  "meta" : {
    "versionId" : "1",
    "lastUpdated" : "2016-06-15T08:16:14Z",
    "profile" : [
      "http://hl7.org/fhir/StructureDefinition/ccda-operative-note-composition"
    }
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
      <p>Operative Note document for Henry Jones</p>
      <p>Managed by Community Health and Hospitals</p>
    </div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension",
      "valueUri" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497"
    },
    {
      "url" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension",
      "valueUri" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"
    }
  },
  "identifier" : {
    "system" : "http://hl7.org/fhir/ccda/StructureDefinition/ccda-operative-note-composition",
    "value" : "1"
  },
  "date" : "2016-03-22T09:10:14Z",
  "type" : {
    "coding" : [
      {
        "system" : "http://loinc.org",
        "code" : "11504-8",
        "display" : "Provider-unspecified Operation Note"
      }
    }
  },
  "title" : "Operative Note",
  "status" : "preliminary",
  "confidentiality" : "N",
  "subject" : {
    "reference" : "http://fhirtest.uhn.ca/baseDstu3/Patient/117467",
    "display" : "Henry Jones"
  },
  "author" : [
    {
      "reference" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497",
      "display" : "Adam Everyman, MD"
    }
  },
  "attester" : [
    {
      "mode" : [
        "legal"
      },
      "time" : "2012-01-04T09:10:14Z",
      "party" : {
        "reference" : "http://fhirtest.uhn.ca/baseDstu3/Practitioner/117497",
        "display" : "Adam Everyman, MD"
      }
    }
  },
  "custodian" : {
    "reference" : "http://fhirtest.uhn.ca/baseDstu3/Organization/117471",
    "display" : "Community Health and Hospitals"
  },
  "event" : [
    {
      "code" : [
        {
          "coding" : [
            {
              "system" : "http://snomed.info/sct",
              "code" : "73761001",
              "display" : "Colonoscopy"
            }
          }
        }
      },
      "period" : {
        "start" : "2015-11-18",
        "end" : "2015-12-12"
      }
    }
  },
  "encounter" : {
    "reference" : "http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"
  },
  "section" : [
    {
      "title" : "Allergies and Intolerances Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "48765-2",
            "display" : "Allergies and adverse reactions"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      },
      "mode" : "snapshot",
      "orderedBy" : {
        "coding" : [
          {
            "system" : "http://hl7.org/fhir/list-order",
            "code" : "event-date",
            "display" : "Sorted by Event Date"
          }
        }
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"
        }
      }
    },
    {
      "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">
        <p>Conscious sedation with propofol 200 mg IV</p>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Medication/117679"
        }
      }
    },
    {
      "title" : " Assessment Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "51848-0",
            "display" : "Assessment (evaluation)"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      }
    },
    {
      "title" : "Assessment and Plan Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "51847-2",
            "display" : "Assessment (evaluation) and plan"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      }
    },
    {
      "title" : "Complications Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "55109-3",
            "display" : "Complications"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>Asthmatic symptoms while under general anesthesia.</p>
      </div>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Condition/117648"
        }
      }
    },
    {
      "title" : "Preoperative Diagnosis Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10219-4",
            "display" : "Preoperative Diagnosis"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>Appendicitis</p>
      </div>"
      }
    },
    {
      "title" : "Operative Note Surgical Procedure Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10223-6",
            "display" : "Operative Note Surgical Procedure"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>Laparoscopic Appendectomy</p>
      </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">
        <p>Colonoscopy</p>
      </div>"
      }
    },
    {
      "title" : "Procedure Indications Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59768-2",
            "display" : "Procedure indications"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>The procedure is performed for screening in a low risk individual.</p>
      </div>"
      }
    },
    {
      "title" : "Procedure Description Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "29554-3",
            "display" : "Procedure description"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      }
    },
    {
      "title" : "Procedure Estimated Blood Loss Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59770-8",
            "display" : "Procedure Estimated Blood Loss"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>Minimal</p>
      </div>"
      }
    },
    {
      "title" : "Procedure Findings Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59776-5",
            "display" : "Procedure findings"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>"
      },
      "entry" : [
        {
          "reference" : "http://fhirtest.uhn.ca/baseDstu3/Condition/117648"
        }
      }
    },
    {
      "title" : "Procedure Specimens Taken Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59773-2",
            "display" : "Procedure specimens taken"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>Ascending colon polyp</p>
      </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">
        <p>250 ML Ringers Lactate</p>
      </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">
        <p>Penrose drain placed</p>
      </div>"
      }
    },
    {
      "title" : "Procedure Implants Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59771-6",
            "display" : "Procedure implants"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>No implants were placed.</p>
      </div>"
      }
    },
    {
      "title" : "Procedure Disposition Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "59775-7",
            "display" : "Procedure disposition"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>The patient was taken to the Endoscopy Recovery Unit in stable condition.</p>
      </div>"
      }
    },
    {
      "title" : "Postoperative Diagnosis Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "10218-6",
            "display" : "Postoperative Diagnosis"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<div xmlns="http://www.w3.org/1999/xhtml">
        <p>Appendicitis with periappendiceal abscess</p>
      </div>"
      }
    },
    {
      "title" : "Plan of Treatment Section",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "18776-5",
            "display" : "Plan of treatment"
          }
        }
      },
      "text" : {
        "status" : "generated",
        "div" : "<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>2010/08/16 - 2010/08/16</td>
            <td>Completed</td>
          </tr>
          <tr>
            <td>Recommendation to Exercise</td>
            <td>2015/10/29</td>
            <td>Ongoing</td>
          </tr>
        </table>
      </div>"
      }
    }
  }
}