OperativeNote

Operative Note

activeC-CDA on FHIR1.2.0resource72 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.

Metadata

hl7.org/fhir

Canonical URL: http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note
ID: Operative-Note
Type
Base Definition: US-Realm-Header
Derivation: constraint

Mandatory and Must-Support Elements

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

Path	Card.	Type	Flags	Description
type			S	type
:anesthesia_section	1..1		S1+	Anesthesia Section
section.title			S1+	title
section.code			S1+	Anesthesia
section.text			S1+	text
:anesthesia_entry		Reference	S
:complications_section	1..1		S1+	Complications Section
section.title			S1+	title
section.code			S1+	Complications
section.text			S1+	text
:complications_entry		Reference	S
:preoperative_diagnosis_section	1..1		S1+	Preoperative Diagnosis Section
section.title			S1+	title
section.code			S1+	Preoperative Diagnosis
section.text			S1+	text
:preoperative_diagnosis_entry		Reference	S
:procedure_estimated_blood_loss_section	1..1		S1+	Procedure Estimated Blood Loss Section
section.title			S1+	title
section.code			S1+	Procedure Estimated Blood Loss
section.text			S1+	This section contains only human readable content
:procedure_findings_section	1..1		S1+	Procedure Findings Section
section.title			S1+	title
section.code			S1+	Procedure Findings
section.text			S1+	text
:procedure_findings_entry		Reference	S
:procedure_specimens_taken_section	1..1		S1+	Procedure Specimens Taken Section
section.title			S1+	title
section.code			S1+	Procedure Specimens Taken
section.text			S1+	This section contains only human readable content
:postoperative_diagnosis_section	1..1		S1+	Postoperative Diagnosis Section
section.title			S1+	title
section.code			S1+	Postoperative Diagnosis
section.text			S1+	This section contains only human readable content
:procedure_description_section	1..1		S1+	Procedure Description Section
section.title			1+	title
section.code			S1+	Procedure Description
section.text			S1+	This section contains only human readable content
:operative_note_surgical_procedure_section			S	Operative Note Surgical Procedure Section
section.title			S1+	title
section.code			S1+	Operative Note Surgical Procedure
section.text			S1+	This section contains only human readable content
:operative_note_fluids_section			S	Operative Note Fluids Section
section.title			S1+	title
section.code			S1+	Operative Note Fluids
section.text			S1+	This section contains only human readable content
:plan_of_treatment_section			S	Plan of Treatment Section
section.title			S1+	title
section.code			S1+	Plan of Treatment
section.text			S1+	text
section.entry			S	entry
:planned_procedure_section			S	Planned Procedure Section
section.title			S1+	title
section.code			S1+	Planned Procedure
section.text			S1+	text
:planned_procedure_entry		Reference	S	This section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
:procedure_disposition_section			S	Procedure Disposition Section
section.title			S1+	title
section.code			S1+	Procedure Disposition
section.text			S1+	This section contains only human readable content
:procedure_indications_section			S	Procedure Indications Section
section.title			S1+	title
section.code			S1+	Procedure Indications
section.text			S1+	This section contains only human readable content
:problem_entry		Reference	S
:procedure_implants_section			S	Procedure Implants Section
section.title			S1+	title
section.code			S1+	Procedure Implants
section.text			S1+	This section contains only human readable content
:surgical_drains_section			S	Surgical Drains Section
section.title			S1+	title
section.code			S1+	Surgical Drains
section.text			S1+	This section contains only human readable content