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

{title?}

<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/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note"/>
  </meta>
  <language value="en-US"/>
  <text>
    <status value="generated"/>
    <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>
  </text>
<!--  <extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-data-enterer-extension"><valueUri value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-informant-extension"><valueUri value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-information-recipient-extension"><valueUri value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-participant-extension"><valueUri value="http://fhirtest.uhn.ca/baseDstu3/RelatedPerson/117466"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-performer-extension"><valueUri value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/></extension><extension url="http://hl7.org/fhir/ccda/StructureDefinition/ccda-authorization-extension"><valueUri value="http://hl7.org/fhir/ccda/StructureDefinition/ccda-consent"/></extension> -->
  <identifier>
    <system
            value="http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Operative-Note"/>
    <value value="1"/>
  </identifier>
  <date value="2016-03-22T09:10:14Z"/>
  <type>
    <coding>
      <system value="http://loinc.org"/>
      <code value="11504-8"/>
      <display value="Provider-unspecified Operation Note"/>
    </coding>
  </type>
  <title value="Operative Note"/>
  <status value="preliminary"/>
  <confidentiality value="N"/>
<!--   Patient Resource  -->
  <subject>
    <reference
               value="http://fhir3.healthintersections.com.au/open/Patient/c493f2f2-28d5-49ab-90e8-9e8be341f7"/>
    <display value="Henry Jones"/>
  </subject>
<!--   Practitioner Resource  -->
  <author>
    <reference
               value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/>
    <display value="Adam Everyman, MD"/>
  </author>
  <attester>
    <mode value="legal"/>
    <time value="2012-01-04T09:10:14Z"/>
    <party>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Practitioner/2679baa7-5dac-4d22-81ae-daded84500"/>
      <display value="Adam Everyman, MD"/>
    </party>
  </attester>
<!--   Organization Resource  -->
  <custodian>
    <reference
               value="http://fhir3.healthintersections.com.au/open/Organization/1213e1ae-afc2-4a7c-8ed3-43b7a4e3d7"/>
    <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="2015-11-18"/>
      <end value="2015-12-12"/>
    </period>
  </event>
<!--   Encounter Resource  -->
  <encounter>
    <reference value="http://fhirtest.uhn.ca/baseDstu3/Encounter/117630"/>
  </encounter>
<!--   Allergies and Intolerances Section Narrative  -->
<!--   Allergies and Intolerances Section Resource  -->
<!--    <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/AllergyIntolerance/117632"/></entry> -->
  <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>
  </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 Procedure Resource  -->
  <!--  SG: Commenting out for now as I've had to remove from the profile  -->
  <!-- <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/Procedure/117687"/></entry> -->
  <!--   Anesthesia Section Medication Resource  -->
    <entry>
      <reference
                 value="http://fhir3.healthintersections.com.au/open/Medication/73bdc4a1-736c-4d79-8f42-620a19a367"/>
    </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="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/>
    </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  -->
<!--   Procedure Findings Section Condition Resource  -->
<!--   <entry><reference value="http://fhirtest.uhn.ca/baseDstu3/Condition/117648"/></entry> -->
  <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>
  </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>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>
    </text>
  </section>
</Composition>