Draft| Description |
The Procedure Description section records the particulars of the procedure and may include procedure site preparation, surgical site preparation, pertinent details related to sedation/anesthesia, pertinent details related to measurements and markings, procedure times, medications administered, estimated blood loss, specimens removed, implants, instrumentation, sponge counts, tissue manipulation, wound closure, sutures used, vital signs and other monitoring data. Local practice often identifies the level and type of detail required based on the procedure or specialty. |
| Used by 2 transactions and 3 templates, Uses 0 templates | ||||||||||||||||||||||||
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Operative Note (V3)ref
ad1bbr-
| Item | DT | Card | Conf | Description | Label |
|---|---|---|---|---|---|
| cda:section | Proc tion | ||||
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:81-8062) such that it | CONF8062 |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.2.27 | CONF0442 |
| SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.2.27" (CONF:81-10442). | |||||
| cda:code | CE | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:81-15411). | CONF5411 |
| @code | CONF | 1 … 1 | F | 29554-3 | |
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 | ||
| cda:title | ST | 1 … 1 | SHALL contain exactly one [1..1] title (CONF:81-8064). | CONF8064 | |
| cda:text | SD.TEXT | 1 … 1 | R | SHALL contain exactly one [1..1] text (CONF:81-8065). | CONF8065 |