Operative Note

The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.

The Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.

resourceCompositionactiveView in C-CDA on FHIR IG

Profile Name

OperativeNote

Canonical URL

http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note

Base Definition

US-Realm-Header

Derivation

constraint

Differential Elements (81)

Constraints and modifications from the base definition

Path	Cardinality	Type(s)	Must Support	Details
`Composition`	-	-	-	-
`Composition.type`	-	-	Yes	-
`Composition.section`	-	-	-	-
`Composition.section` Slice: anesthesia_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: anesthesia_entry	-	Reference	Yes	Target: `MedicationStatementus-core-medicationus-core-medicationrequestus-core-procedure`
`Composition.section` Slice: complications_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: complications_entry	-	Reference	Yes	Target: `us-core-condition`
`Composition.section` Slice: preoperative_diagnosis_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: preoperative_diagnosis_entry	-	Reference	Yes	Target: `us-core-condition`
`Composition.section` Slice: procedure_estimated_blood_loss_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: procedure_findings_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: procedure_findings_entry	-	Reference	Yes	Target: `us-core-condition`
`Composition.section` Slice: procedure_specimens_taken_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: postoperative_diagnosis_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: procedure_description_section	`1..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	-	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: operative_note_surgical_procedure_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: operative_note_fluids_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: plan_of_treatment_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	Yes	-
`Composition.section.entry` Slice: sliceEntry	-	Reference	-	Target: `us-core-goalus-core-medicationrequestus-core-encounterCommunicationAppointmentCommunicationRequestDeviceRequestNutritionOrderTaskServiceRequestVisionPrescriptionRequestGroup`
`Composition.section` Slice: planned_procedure_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: planned_procedure_entry	-	Reference	Yes	Target: `ServiceRequest`
`Composition.section` Slice: procedure_disposition_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: procedure_indications_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section.entry`	-	-	-	-
`Composition.section.entry` Slice: problem_entry	-	Reference	Yes	Target: `us-core-condition`
`Composition.section` Slice: procedure_implants_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-
`Composition.section` Slice: surgical_drains_section	`*..1`	-	Yes	-
`Composition.section.title`	`1..*`	-	Yes	-
`Composition.section.code`	`1..*`	-	Yes	-
`Composition.section.text`	`1..*`	-	Yes	-