Draft| Description |
The Preoperative Diagnosis entry encodes the surgical diagnosis or diagnoses assigned to the patient before the surgical procedure and is the reason for the surgery. The preoperative diagnosis is, in the opinion of the surgeon, the diagnosis that will be confirmed during surgery. |
| Used by 1 transaction and 2 templates, Uses 1 template | ||||||||||||||||||||||||
|
Operative Note (Release 1.1)
| Item | DT | Card | Conf | Description | Label |
|---|---|---|---|---|---|
| cda:act | Preo osis | ||||
| @classCode | cs | 1 … 1 | F | ACT | conf0090 |
| @moodCode | cs | 1 … 1 | F | EVN | conf0091 |
| cda:templateId | II | 1 … 1 | M | SHALL contain exactly one [1..1] templateId (CONF:16770) such that it | conf6770 |
| @root | uid | 1 … 1 | F | 2.16.840.1.113883.10.20.22.4.65 | conf6771 |
| cda:code | CD | 1 … 1 | M | SHALL contain exactly one [1..1] code (CONF:19155). | conf9155 |
| @code | CONF | 1 … 1 | F | 10219-4 | |
| @codeSystem | 1 … 1 | F | 2.16.840.1.113883.6.1 | ||
| cda:entryRelationship | 1 … * | M | Contains 2.16.840.1.113883.10.20.22.4.4 Problem Observation (2013‑01‑31) | conf0093 | |
| @typeCode | cs | 1 … 1 | F | SUBJ | conf0094 |