OperativeNote

Operative Note

activeC-CDA Templates4.0.0logical23 key elements

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.

#### Document Sections Although document templates may contain any section, the following sections are specifically called out by this template:

Required Sections

  • AnesthesiaSection
  • ComplicationsSection
  • PreoperativeDiagnosisSection
  • ProcedureEstimatedBloodLossSection
  • ProcedureFindingsSection
  • ProcedureSpecimensTakenSection
  • ProcedureDescriptionSection
  • PostoperativeDiagnosisSection

Additional Sections

  • ProcedureImplantsSection
  • OperativeNoteFluidsSection
  • OperativeNoteSurgicalProcedureSection
  • PlanofTreatmentSection
  • PlannedProcedureSection
  • ProcedureDispositionSection
  • ProcedureIndicationsSection
  • SurgicalDrainsSection
  • AdvanceDirectivesSection

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote
ID
OperativeNote
Type
Base Definition
USRealmHeader
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
templateId
1+
:operative-note1..1
1+
templateId.root
1+
templateId.extension
1+
sdtcCategory.code
1+
sdtcCategory.codeSystem
1+
documentationOf
1+
A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements.
documentationOf.serviceEvent.code
1+
documentationOf.serviceEvent.performer
1+
:primary1..*
1+
This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant.
authorization.typeCode
1+
authorization.consent.classCode
1+
authorization.consent.moodCode
1+
component.structuredBody
1+
component.structuredBody.component
1+
:anesthesia1..1
1+
:complications1..1
1+
:preopDx1..1
1+
:estBloodLoss1..1
1+
:findings1..1
1+
:specimensTaken1..1
1+
:procedureDescription1..1
1+
:postopDx1..1
1+