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Template Operative Note 2013‑01‑31

Id2.16.840.1.113883.10.20.22.1.7Effective Date2013‑01‑31
Statusdraft DraftVersion Label1.1
NameOperativeNoteDisplay NameOperative Note
Description
The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. The Operative Note or Report is created immediately following a surgical or other high-risk procedure and 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.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 16 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.6Transactionfinal Operative Note (Release 1.1)2013‑01‑31
Uses as NameVersion
2.16.840.1.113883.10.20.7.12Containmentdraft Operative Note Fluids Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.7.13Containmentdraft Surgical Drains Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.7.14Containmentdraft Operative Note Surgical Procedure Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.18.2.9Containmentdraft Procedure Estimated Blood Loss Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.18.2.12Containmentdraft Procedure Disposition Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Care Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.27Containmentdraft Procedure Description Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.28Containmentdraft Procedure Findings Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.29Containmentdraft Procedure Indications Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.30Containmentdraft Planned Procedure Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.31Containmentdraft Procedure Specimens Taken Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.34Containmentdraft Preoperative Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.35Containmentdraft Postoperative Diagnosis Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.37Containmentdraft Complications Section (1.1)2013‑01‑31
2.16.840.1.113883.10.20.22.2.40Containmentdraft Procedure Implants Section (1.1)2013‑01‑31
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent.OperdotsNote
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:8483) such that itconf‑8483
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.7confdots0048
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:17187).confdots7187
cda:documentationOf
1 … *MSHALL contain at least one [1..*] documentationOf (CONF:8486).

Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF).		conf‑8486
cda:serviceEvent
1 … 1MSuch documentationOfs SHALL contain exactly one [1..1] serviceEvent (CONF:8493).

i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC		conf‑8493
cda:code
CE1 … i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMICconf‑8493
 CONF
@codeSystem shall be "2.16.840.1.113883.6.104"
or
@codeSystem shall be "2.16.840.1.113883.6.12"
or
@codeSystem shall be "2.16.840.1.113883.6.96"
cda:effectiveTime
IVL_TS1 … 1MThis serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8494).

The serviceEvent/effectiveTime SHALL be present with effectiveTime/low.

If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high

When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)		conf‑8494
 Schematron assertrolered error 
 testnot(.//@value[not(parent::cda:width)][string-length()<8]) 
 MessageThe content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4) 
cda:low
TS1 … 1The serviceEvent/effectiveTime element SHOULD be present with effectiveTime/low element. The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)conf‑8494
Choice1 … 1
If a width element is not present, the serviceEvent SHALL include effectiveTime/high
Elements to choose from:
  • cda:width
  • cda:high
cda:width
PQRconf‑8494
cda:high
TSconf‑8494
cda:performer
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] performer (CONF:8489) such that itconf‑8489
@typeCode
cs1 … 1FPPRFconf‑8495
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:10917).confdots0917
cda:code
CE1 … 1This assignedEntity SHALL contain exactly one [1..1] code (CONF:8490).conf‑8490
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:9585).

An Operative Note can have either a structuredBody or a nonXMLBody

An Operative Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.7), coded entries are optional

If structuredBody, the component/structuredBody SHALL conform to the section constraints below		conf‑9585
Choice1 … 1
An Operative Note can have either a structuredBody or a nonXMLBody
Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
cda:nonXMLBody
conf‑9585
cda:structuredBody
conf‑9585
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (2013‑01‑31)conf‑9883
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (2013‑01‑31)conf‑9885
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.34 Preoperative Diagnosis Section (2013‑01‑31)conf‑9888
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (2013‑01‑31)conf‑9890
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (2013‑01‑31)conf‑9892
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (2013‑01‑31)conf‑9894
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (2013‑01‑31)conf‑9896
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (2013‑01‑31)conf‑9898
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.7.12 Operative Note Fluids Section (2013‑01‑31)conf‑9900
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.7.14 Operative Note Surgical Procedure Section (2013‑01‑31)conf‑9902
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (2013‑01‑31)conf‑9904
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (2013‑01‑31)conf‑9906
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (2013‑01‑31)conf‑9908
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (2013‑01‑31)conf‑9910
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.7.13 Surgical Drains Section (2013‑01‑31)conf‑9912
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.35 Postoperative Diagnosis Section (2013‑01‑31)conf‑9913