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Template Operative Note (V3) 2015‑08‑01

Id2.16.840.1.113883.10.20.22.1.7Effective Date2015‑08‑01
Statusdraft DraftVersion Label2.1
NameOperativeNoteV3Display NameOperative Note (V3)
Description
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.
ContextPathname //
ClassificationCDA Document Level Template
Open/ClosedOpen (other than defined elements are allowed)
Used by / Uses
Used by 1 transaction and 0 templates, Uses 17 templates
Used by as NameVersion
2.16.840.1.113883.3.1937.99.3.4.27Transactionfinal Operative Note (V3)2015‑08‑01
Uses as NameVersion
2.16.840.1.113883.10.20.7.12Containmentdraft Operative Note Fluids Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.7.13Containmentdraft Surgical Drains Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.7.14Containmentdraft Operative Note Surgical Procedure Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.18.2.9Containmentdraft Procedure Estimated Blood Loss Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.18.2.12Containmentdraft Procedure Disposition Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.10Containmentdraft Plan of Treatment Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.25Containmentdraft Anesthesia Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.27Containmentdraft Procedure Description Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.28Containmentdraft Procedure Findings Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.29Containmentdraft Procedure Indications Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.30Containmentdraft Planned Procedure Section (V2) (2.1)2014‑06‑09
2.16.840.1.113883.10.20.22.2.31Containmentdraft Procedure Specimens Taken Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.34Containmentdraft Preoperative Diagnosis Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.35Containmentdraft Postoperative Diagnosis Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.2.37Containmentdraft Complications Section (V3) (2.1)2015‑08‑01
2.16.840.1.113883.10.20.22.2.40Containmentdraft Procedure Implants Section (2.1)2015‑08‑13
2.16.840.1.113883.10.20.22.5.3Containmentdraft US Realm Date and Time (DT.US.FIELDED) (2.1)2015‑08‑13
RelationshipSpecialization: template 2.16.840.1.113883.10.12.1 CDA ClinicalDocument (2005‑09‑07)
ref
ad1bbr-

Specialization: template 2.16.840.1.113883.10.20.22.1.1 US Realm Header (V3) (2015‑08‑01)
Version: template 2.16.840.1.113883.10.20.22.1.7 Operative Note (2013‑01‑31)
ItemDTCardConfDescriptionLabel
cda:ClinicalDocument
R When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 SHALLinclude both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32940).
OperdotsteV3
cda:templateId
II1 … 1MC-CDA R1.1 templateId root without an extensionCONFdots2936
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.7
cda:templateId
II1 … 1MSHALL contain exactly one [1..1] templateId (CONF:1198-8483) such that itCONFdots8483
@root
uid1 … 1F2.16.840.1.113883.10.20.22.1.7CONFdots0048
 SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.7" (CONF:1198-10048).
@extension
st1 … 1F2015-08-01CONFdots2519
 SHALL contain exactly one [1..1] @extension="2015-08-01" (CONF:1198-32519).
cda:code
1 … 1SHALL contain exactly one [1..1] code (CONF:1198-17187).

The Operative Note recommends use of a single document type code, 11504-8 "Provider-unspecified Operation Note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.		CONFdots7187
cda:documentationOf
1 … *MSHALL contain at least one [1..*] documentationOf (CONF:1198-8486).

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.		CONFdots8486
cda:serviceEvent
1 … 1MContains 2.16.840.1.113883.10.20.22.5.3 US Realm Date and Time (DT.US.FIELDED) (2015‑08‑13)CONFdots8493
cda:code
1 … The value of 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:1198-8487).CONFdots8487
 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"
or
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.80.28 (DYNAMIC)
cda:performer
1 … 1MThis serviceEvent SHALL contain exactly one [1..1] performer (CONF:1198-8489) such that itCONFdots8489
where [@typeCode='PPRF']
@typeCode
cs1 … 1FPPRFCONFdots8495
 SHALL contain exactly one [1..1] @typeCode="PPRF" Primary performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90 STATIC) (CONF:1198-8495).
cda:functionCode
CE0 … 1MAY contain zero or one [0..1] functionCode, which SHOULD be selected from ValueSet Care Team Member Function urn:oid:2.16.840.1.113762.1.4.1099.30 DYNAMIC (CONF:1198-32963).CONFdots2963
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1099.30 Care Team Member Function (DYNAMIC)
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:1198-10917).CONFdots0917
cda:code
CE0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-8490).CONFdots8490
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:performer
0 … *This performer represents any assistants.

This serviceEvent MAY contain zero or more [0..*] performer (CONF:1198-32736) such that it		CONFdots2736
where [@typeCode='SPRF']
@typeCode
cs1 … 1FSPRFCONFdots2738
 SHALL contain exactly one [1..1] @typeCode="SPRF" Secondary performer (CodeSystem: HL7ParticipationType urn:oid:2.16.840.1.113883.5.90) (CONF:1198-32738).
cda:functionCode
CE0 … 1 MAY contain zero or one [0..1] functionCode, which SHOULD be selected from ValueSet Care Team Member Function urn:oid:2.16.840.1.113762.1.4.1099.30 DYNAMIC (CONF:1198-32964).CONFdots2964
 CONF
The value of @code shall be drawn from value set 2.16.840.1.113762.1.4.1099.30 Care Team Member Function (DYNAMIC)
cda:assignedEntity
1 … 1MSHALL contain exactly one [1..1] assignedEntity (CONF:1198-32737).CONFdots2737
cda:code
CE0 … 1RThis assignedEntity SHOULD contain zero or one [0..1] code, which SHALL be selected from ValueSet Healthcare Provider Taxonomy (HIPAA) urn:oid:2.16.840.1.114222.4.11.1066 DYNAMIC (CONF:1198-32739).CONFdots2739
 CONF
The value of @code shall be drawn from value set 2.16.840.1.114222.4.11.1066 Healthcare Provider Taxonomy (DYNAMIC)
cda:authorization
0 … 1MAY contain zero or one [0..1] authorization (CONF:1198-32404).

Authorization represents consent. Consent, if present, shall be represented by authorization/consent.		CONFdots2404
@typeCode
cs1 … 1FAUTHCONFdots2408
 The authorization, if present, SHALL contain exactly one [1..1] @typeCode="AUTH" authorized by (CodeSystem: HL7ActRelationshipType urn:oid:2.16.840.1.113883.5.1002) (CONF:1198-32408).
cda:consent
1 … 1MThe authorization, if present, SHALL contain exactly one [1..1] consent (CONF:1198-32405).CONFdots2405
@classCode
cs1 … 1FCONSCONFdots2409
 This consent SHALL contain exactly one [1..1] @classCode="CONS" consent (CodeSystem: HL7ActClass urn:oid:2.16.840.1.113883.5.6) (CONF:1198-32409).
@moodCode
cs1 … 1FEVNCONFdots2410
 This consent SHALL contain exactly one [1..1] @moodCode="EVN" event (CodeSystem: ActMood urn:oid:2.16.840.1.113883.5.1001) (CONF:1198-32410).
cda:statusCode
CS1 … 1RThis consent SHALL contain exactly one [1..1] statusCode (CONF:1198-32411).CONFdots2411
cda:component
1 … 1MSHALL contain exactly one [1..1] component (CONF:1198-9585).CONFdots9585
cda:structuredBody
1 … 1MThis component SHALL contain exactly one [1..1] structuredBody (CONF:1198-30485).CONFdots0485
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (V2) (2014‑06‑09)CONFdots0486
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (V3) (2015‑08‑01)CONFdots0488
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.34 Preoperative Diagnosis Section (V3) (2015‑08‑01)CONFdots0490
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (2015‑08‑13)CONFdots0492
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (V3) (2015‑08‑01)CONFdots0494
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (2015‑08‑13)CONFdots0496
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (2015‑08‑13)CONFdots0498
cda:component
1 … 1Contains 2.16.840.1.113883.10.20.22.2.35 Postoperative Diagnosis Section (2015‑08‑13)CONFdots0500
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (2015‑08‑13)CONFdots0502
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.7.12 Operative Note Fluids Section (2015‑08‑13)CONFdots0504
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.7.14 Operative Note Surgical Procedure Section (2015‑08‑13)CONFdots0506
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Treatment Section (V2) (2014‑06‑09)CONFdots0508
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (V2) (2014‑06‑09)CONFdots0510
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (2015‑08‑13)CONFdots0512
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (V2) (2014‑06‑09)CONFdots0514
cda:component
0 … 1Contains 2.16.840.1.113883.10.20.7.13 Surgical Drains Section (2015‑08‑13)CONFdots0516