Current Build
This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. 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-on-FHIR-Operative-Note-Example",
"meta" : {
"versionId" : "1",
"lastUpdated" : "2016-06-15T08:16:14Z",
"profile" : [
"http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note"
]
},
"language" : "en-US",
"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>"
},
"identifier" : {
"system" : "http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note",
"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://fhir3.healthintersections.com.au/open/Patient/c493f2f2-28d5-49ab-90e8-9e8be341f7",
"display" : "Henry Jones"
},
"author" : [
{
"reference" : "http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500",
"display" : "Adam Everyman, MD"
}
],
"attester" : [
{
"mode" : [
"legal"
],
"time" : "2012-01-04T09:10:14Z",
"party" : {
"reference" : "http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500",
"display" : "Adam Everyman, MD"
}
}
],
"custodian" : {
"reference" : "http://fhir3.healthintersections.com.au/open/Organization/1213e1ae-afc2-4a7c-8ed3-43b7a4e3d7",
"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"
}
]
}
},
{
"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://fhir3.healthintersections.com.au/open/Medication/73bdc4a1-736c-4d79-8f42-620a19a367"
}
]
},
{
"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>"
}
},
{
"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>"
}
}
]
}
© HL7.org 2011+. FHIR STU3 Candidate (v1.8.0-10514) generated on Thu, Dec 8, 2016 06:39+1100. QA Page
Links: Search |
Version History |
Table of Contents |
|
Propose a change