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
<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>