C-CDA on FHIR
1.2.0 - STU 1
C-CDA on FHIR
1.2.0 - STU 1
C-CDA on FHIR, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 1.2.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/ccda-on-fhir/ and changes regularly. See the Directory of published versions
<Composition xmlns="http://hl7.org/fhir">
<id value="Operative-Note-Example"/>
<meta>
<versionId value="4"/>
<lastUpdated value="2020-08-12T21:30:19.501+00:00"/>
<source value="#csn482LCsnDWyxbW"/>
<profile
value="http://hl7.org/fhir/us/ccda/StructureDefinition/Operative-Note"/>
</meta>
<language value="en-US"/>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US">
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Id</span>
</td>
<td class="td_header_role_value">12345</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document Created:</span>
</td>
<td class="td_header_role_value">June 15, 2016, 16:14, PST </td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care Provision</span>
</td>
<td class="td_header_role_value">Operation Note for Amy
Shaw</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Performer </span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Author</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Id</span>
</td>
<td class="td_header_role_value">9937012
2.16.840.1.113883.19</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Event Type</span>
</td>
<td class="td_header_role_value">Surgery</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Event Date</span>
</td>
<td class="td_header_role_value"> From June 15, 2016, 16:20 to
June 15, 2016, 18:20 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Encounter Location</span>
</td>
<td class="td_header_role_value">Perioperative Department at
Community Health and Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Responsible party</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Assigned entity</span>
</td>
<td class="td_header_role_value">Community Health and Hospitals
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Emergency contact</span>
</td>
<td class="td_header_role_value">Michael Shaw
<br/>
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1212
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Care giver</span>
</td>
<td class="td_header_role_value">Mrs. Lillian White
<br/>
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">49 Meadow St
<br/>Amherst MA
01003, US
<br/>Tel: (555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Entered by</span>
</td>
<td class="td_header_role_value">Sally Jones</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Signed </span>
</td>
<td class="td_header_role_value">Ronald Boone at June 15, 2016
</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Informant</span>
</td>
<td class="td_header_role_value">Henry Vincent, CPh</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1007 Pharmacy Drive
<br/>Portland, OR 99123, US
<br/>Tel: +1(555)555-1215
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Information recipient:</span>
</td>
<td class="td_header_role_value">Primary Physician, MD</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1005 St. Clair Avenue
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1666
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Legal authenticator</span>
</td>
<td class="td_header_role_value">Ronald Boone, MD signed at June
15, 2016 </td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
<table style="border: 1pt inset #00008b; line-height: 10pt; width: 100%;" class="header_table">
<tbody>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Document maintained by</span>
</td>
<td class="td_header_role_value">Community Health and
Hospitals</td>
</tr>
<tr>
<td style="width: 20%; background-color: #3399ff; padding: 0.1cm 0.2cm; vertical-align: top; background-color: #ffffcc;" class="td_header_role_name">
<span class="td_label">Contact info</span>
</td>
<td class="td_header_role_value">1003 Healthcare Drive
<br/>Amherst MA 01002, US
<br/>Tel: +1(555)555-1003
<br/>
</td>
</tr>
</tbody>
</table>
</div>
</text>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:75a12dcd-f85d-4c7f-b1de-38a1a2b7498f"/>
</identifier>
<status value="preliminary"/>
<type>
<coding>
<system value="http://loinc.org"/>
<code value="11504-8"/>
<display value="Surgical operation note"/>
</coding>
</type>
<subject>🔗
<reference value="Patient/example"/>
<display value="Amy V. Shaw"/>
</subject>
<date value="2016-06-15T09:10:14Z"/>
<author>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Bone, MD"/>
</author>
<title value="Operative Note"/>
<attester>
<mode value="legal"/>
<time value="2016-06-15T09:10:14Z"/>
<party>🔗
<reference value="PractitionerRole/ccda-practitionerrole-example"/>
<display value="Ronald Boone, MD"/>
</party>
</attester>
<custodian>🔗
<reference value="Organization/organization-1"/>
<display value="Community Health and Hospitals"/>
</custodian>
<event>
<code>
<coding>
<system value="http://snomed.info/sct"/>
<code value="73761001"/>
<display value="Colonoscopy"/>
</coding>
</code>
<period>
<start value="2016-06-15"/>
<end value="2016-06-15"/>
</period>
</event>
<!--
<section>
<title value="Allergies and Intolerances Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="48765-2"/>
<display value="Allergies and adverse reactions Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div
xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Substance</b>
</td>
<td>
<b>Overall Severity</b>
</td>
<td>
<b>Reaction</b>
</td>
<td>
<b>Reaction Severity</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Cashew Nut</td>
<td>Severe</td>
<td>Anaphylactic reaction</td>
<td>Mild</td>
<td>Active</td>
</tr>
</table>
</div>
</text>
<entry>
<reference value="AllergyIntolerance/allergy-intolerance"/>
</entry>
</section>
-->
<!--
<entry>
<reference value="Condition/condition-problem"/>
</entry>
-->
<section>
<title value="Anesthesia Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59774-0"/>
<display value="Anesthesia"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Conscious sedation with propofol 200 mg IV</p>
</div>
</text>
</section>
<!--
<section>
<title value="Assessment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51848-0"/>
<display value="Evaluation note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div
xmlns="http://www.w3.org/1999/xhtml">
<p>Obesity.</p>
<p>Uncontrolled brittle Type II diabetic.</p>
<p>Shortness of breath, mild wheezing.</p>
<p>Pressure ulder on left knee.</p>
</div>
</text>
</section>
<section>
<title value="Assessment and Plan Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="51847-2"/>
<display value="Evaluation + Plan note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div
xmlns="http://www.w3.org/1999/xhtml">
<p>Recurrent GI bleed of unknown etiology; hypotension perhaps secondary
to this but as likely secondary to polypharmacy</p>
<p>Acute on chronic anemia secondary to #1.</p>
<p>Azotemia, acute renal failure with volume loss secondary tom#1.</p>
<p>Hyperkalemia secondary to #3 and on ACE and K+ supplement.</p>
<p>Other chronic diagnoses as noted above, currently stable.</p>
</div>
</text>
</section>
-->
<section>
<title value="Complications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="55109-3"/>
<display value="Complications Document"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Asthmatic symptoms while under general anesthesia.</p>
</div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="Preoperative Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10219-4"/>
<display
value="Surgical operation note preoperative diagnosis Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Appendicitis</p>
</div>
</text>
</section>
<section>
<title value="Operative Note Surgical Procedure Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10223-6"/>
<display
value="Surgical operation note surgical procedure Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Laparoscopic Appendectomy</p>
</div>
</text>
</section>
<section>
<title value="Planned Procedure Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59772-4"/>
<display value="Planned procedure"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Colonoscopy</p>
</div>
</text>
</section>
<section>
<title value="Procedure Indications Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59768-2"/>
<display value="Procedure indications [Interpretation] Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>The procedure is performed for screening in a low risk
individual.</p>
</div>
</text>
</section>
<section>
<title value="Procedure Description Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="29554-3"/>
<display value="Procedure Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>The patient was brought to the operating room, placed in the supine
position, and general anesthesia was induced. A detailed technical
narrative of a laparoscopic appendectomy from initial incision to
placement of any dressings follows. </p>
</div>
</text>
</section>
<section>
<title value="Procedure Estimated Blood Loss Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59770-8"/>
<display value="Procedure estimated blood loss Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Minimal</p>
</div>
</text>
</section>
<section>
<title value="Procedure Findings Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59776-5"/>
<display value="Procedure findings Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>A 6 mm sessile polyp was found in the ascending colon and removed by
snare, no cautery. Bleeding was controlled. Moderate diverticulosis
and hemorrhoids were incidentally noted.</p>
</div>
</text>
<entry>🔗
<reference value="Condition/condition-problem"/>
</entry>
</section>
<section>
<title value="Procedure Specimens Taken Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59773-2"/>
<display value="Procedure specimens taken Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Ascending colon polyp</p>
</div>
</text>
</section>
<section>
<title value="Operative Note Fluids Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10216-0"/>
<display value="Operative Note Fluids"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>250 ML Ringers Lactate</p>
</div>
</text>
</section>
<section>
<title value="Surgical Drains Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="11537-8"/>
<display value="Surgical Drains"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Penrose drain placed</p>
</div>
</text>
</section>
<section>
<title value="Procedure Implants Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59771-6"/>
<display value="Procedure implants Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>No implants were placed.</p>
</div>
</text>
</section>
<section>
<title value="Procedure Disposition Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="59775-7"/>
<display value="Procedure disposition Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>The patient was taken to the Endoscopy Recovery Unit in stable
condition.</p>
</div>
</text>
</section>
<section>
<title value="Postoperative Diagnosis Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="10218-6"/>
<display
value="Surgical operation note postoperative diagnosis Narrative"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<p>Appendicitis with periappendiceal abscess</p>
</div>
</text>
</section>
<section>
<title value="Plan of Treatment Section"/>
<code>
<coding>
<system value="http://loinc.org"/>
<code value="18776-5"/>
<display value="Plan of care note"/>
</coding>
</code>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table>
<tr>
<td>
<b>Planned Activity</b>
</td>
<td>
<b>Period</b>
</td>
<td>
<b>Status</b>
</td>
</tr>
<tr>
<td>Colonoscopy</td>
<td>2016/09/17 - 2010/09/17</td>
<td>Planned</td>
</tr>
<tr>
<td>Recommendation to Exercise</td>
<td>2016/06/25</td>
<td>Ongoing</td>
</tr>
</table>
</div>
</text>
</section>
</Composition>
IG © 2020+ HL7 International / Cross-Group Projects. Package hl7.fhir.us.ccda#1.2.0 based on FHIR 4.0.1. Generated 2024-03-12
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