C-CDA on FHIR
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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 2.0.0-ballot 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

Resource Profile: OperativeNote - Detailed Descriptions

Active as of 2024-12-17

Definitions for the Operative-Note resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Composition
2. Composition.type
Shorttype
BindingThe codes SHALL be taken from SurgicalOperationNoteDocumentTypeCode
(required to http://hl7.org/fhir/us/ccda/ValueSet/2.16.840.1.113883.11.20.1.1)
Must Supporttrue
4. Composition.section
SlicingThis element introduces a set of slices on Composition.section. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ code
  • 6. Composition.section:anesthesia_section
    Slice Nameanesthesia_section
    ShortAnesthesia Section
    Control1..1
    Must Supporttrue
    LabelAnesthesia Section
    8. Composition.section:anesthesia_section.title
    Shorttitle
    Control1..?
    Must Supporttrue
    10. Composition.section:anesthesia_section.code
    ShortAnesthesia
    Control1..?
    Must Supporttrue
    LabelAnesthesia
    Pattern Value{
      "coding" : [{
        "system" : "http://loinc.org",
        "code" : "59774-0"
      }]
    }
    12. Composition.section:anesthesia_section.text
    Shorttext
    Control1..?
    Must Supporttrue
    14. Composition.section:anesthesia_section.entry
    Shortentry
    SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • profile @ resolve()
    • 16. Composition.section:anesthesia_section.entry:anesthesia_entry
      Slice Nameanesthesia_entry
      TypeReference(MedicationStatement, US Core Medication Profile, US Core MedicationRequest Profile, US Core Procedure Profile)
      Must Supporttrue
      Must Support TypesNo must-support rules about the choice of types/profiles
      18. Composition.section:complications_section
      Slice Namecomplications_section
      ShortComplications Section
      Control1..1
      Must Supporttrue
      LabelComplications Section
      20. Composition.section:complications_section.title
      Shorttitle
      Control1..?
      Must Supporttrue
      22. Composition.section:complications_section.code
      ShortComplications
      Control1..?
      Must Supporttrue
      LabelComplications
      Pattern Value{
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "55109-3"
        }]
      }
      24. Composition.section:complications_section.text
      Shorttext
      Control1..?
      Must Supporttrue
      26. Composition.section:complications_section.entry
      Shortentry
      SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • profile @ resolve()
      • 28. Composition.section:complications_section.entry:complications_entry
        Slice Namecomplications_entry
        TypeReference(US Core Condition Profile)
        Must Supporttrue
        30. Composition.section:preoperative_diagnosis_section
        Slice Namepreoperative_diagnosis_section
        ShortPreoperative Diagnosis Section
        Control1..1
        Must Supporttrue
        LabelPreoperative Diagnosis Section
        32. Composition.section:preoperative_diagnosis_section.title
        Shorttitle
        Control1..?
        Must Supporttrue
        34. Composition.section:preoperative_diagnosis_section.code
        ShortPreoperative Diagnosis
        Control1..?
        Must Supporttrue
        LabelPreoperative Diagnosis
        Pattern Value{
          "coding" : [{
            "system" : "http://loinc.org",
            "code" : "10219-4"
          }]
        }
        36. Composition.section:preoperative_diagnosis_section.text
        Shorttext
        Control1..?
        Must Supporttrue
        38. Composition.section:preoperative_diagnosis_section.entry
        Shortentry
        SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • profile @ resolve()
        • 40. Composition.section:preoperative_diagnosis_section.entry:preoperative_diagnosis_entry
          Slice Namepreoperative_diagnosis_entry
          TypeReference(US Core Condition Profile)
          Must Supporttrue
          42. Composition.section:procedure_estimated_blood_loss_section
          Slice Nameprocedure_estimated_blood_loss_section
          ShortProcedure Estimated Blood Loss Section
          Control1..1
          Must Supporttrue
          LabelProcedure Estimated Blood Loss Section
          44. Composition.section:procedure_estimated_blood_loss_section.title
          Shorttitle
          Control1..?
          Must Supporttrue
          46. Composition.section:procedure_estimated_blood_loss_section.code
          ShortProcedure Estimated Blood Loss
          Control1..?
          Must Supporttrue
          LabelProcedure Estimated Blood Loss
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "59770-8"
            }]
          }
          48. Composition.section:procedure_estimated_blood_loss_section.text
          ShortThis section contains only human readable content
          Control1..?
          Must Supporttrue
          50. Composition.section:procedure_findings_section
          Slice Nameprocedure_findings_section
          ShortProcedure Findings Section
          Control1..1
          Must Supporttrue
          LabelProcedure Findings Section
          52. Composition.section:procedure_findings_section.title
          Shorttitle
          Control1..?
          Must Supporttrue
          54. Composition.section:procedure_findings_section.code
          ShortProcedure Findings
          Control1..?
          Must Supporttrue
          LabelProcedure Findings
          Pattern Value{
            "coding" : [{
              "system" : "http://loinc.org",
              "code" : "59776-5"
            }]
          }
          56. Composition.section:procedure_findings_section.text
          Shorttext
          Control1..?
          Must Supporttrue
          58. Composition.section:procedure_findings_section.entry
          Shortentry
          SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • profile @ resolve()
          • 60. Composition.section:procedure_findings_section.entry:procedure_findings_entry
            Slice Nameprocedure_findings_entry
            TypeReference(US Core Condition Profile)
            Must Supporttrue
            62. Composition.section:procedure_specimens_taken_section
            Slice Nameprocedure_specimens_taken_section
            ShortProcedure Specimens Taken Section
            Control1..1
            Must Supporttrue
            LabelProcedure Specimens Taken Section
            64. Composition.section:procedure_specimens_taken_section.title
            Shorttitle
            Control1..?
            Must Supporttrue
            66. Composition.section:procedure_specimens_taken_section.code
            ShortProcedure Specimens Taken
            Control1..?
            Must Supporttrue
            LabelProcedure Specimens Taken
            Pattern Value{
              "coding" : [{
                "system" : "http://loinc.org",
                "code" : "59773-2"
              }]
            }
            68. Composition.section:procedure_specimens_taken_section.text
            ShortThis section contains only human readable content
            Control1..?
            Must Supporttrue
            70. Composition.section:postoperative_diagnosis_section
            Slice Namepostoperative_diagnosis_section
            ShortPostoperative Diagnosis Section
            Control1..1
            Must Supporttrue
            LabelPostoperative Diagnosis Section
            72. Composition.section:postoperative_diagnosis_section.title
            Shorttitle
            Control1..?
            Must Supporttrue
            74. Composition.section:postoperative_diagnosis_section.code
            ShortPostoperative Diagnosis
            Control1..?
            Must Supporttrue
            LabelPostoperative Diagnosis
            Pattern Value{
              "coding" : [{
                "system" : "http://loinc.org",
                "code" : "10218-6"
              }]
            }
            76. Composition.section:postoperative_diagnosis_section.text
            ShortThis section contains only human readable content
            Control1..?
            Must Supporttrue
            78. Composition.section:procedure_description_section
            Slice Nameprocedure_description_section
            ShortProcedure Description Section
            Control1..1
            Must Supporttrue
            LabelProcedure Description Section
            80. Composition.section:procedure_description_section.title
            Shorttitle
            Control1..?
            82. Composition.section:procedure_description_section.code
            ShortProcedure Description
            Control1..?
            Must Supporttrue
            LabelProcedure Description
            Pattern Value{
              "coding" : [{
                "system" : "http://loinc.org",
                "code" : "29554-3"
              }]
            }
            84. Composition.section:procedure_description_section.text
            ShortThis section contains only human readable content
            Control1..?
            Must Supporttrue
            86. Composition.section:operative_note_surgical_procedure_section
            Slice Nameoperative_note_surgical_procedure_section
            ShortOperative Note Surgical Procedure Section
            Control0..1
            Must Supporttrue
            LabelOperative Note Surgical Procedure Section
            88. Composition.section:operative_note_surgical_procedure_section.title
            Shorttitle
            Control1..?
            Must Supporttrue
            90. Composition.section:operative_note_surgical_procedure_section.code
            ShortOperative Note Surgical Procedure
            Control1..?
            Must Supporttrue
            LabelOperative Note Surgical Procedure
            Pattern Value{
              "coding" : [{
                "system" : "http://loinc.org",
                "code" : "10223-6"
              }]
            }
            92. Composition.section:operative_note_surgical_procedure_section.text
            ShortThis section contains only human readable content
            Control1..?
            Must Supporttrue
            94. Composition.section:operative_note_fluids_section
            Slice Nameoperative_note_fluids_section
            ShortOperative Note Fluids Section
            Control0..1
            Must Supporttrue
            LabelOperative Note Fluids Section
            96. Composition.section:operative_note_fluids_section.title
            Shorttitle
            Control1..?
            Must Supporttrue
            98. Composition.section:operative_note_fluids_section.code
            ShortOperative Note Fluids
            Control1..?
            Must Supporttrue
            LabelOperative Note Fluids
            Pattern Value{
              "coding" : [{
                "system" : "http://loinc.org",
                "code" : "10216-0"
              }]
            }
            100. Composition.section:operative_note_fluids_section.text
            ShortThis section contains only human readable content
            Control1..?
            Must Supporttrue
            102. Composition.section:plan_of_treatment_section
            Slice Nameplan_of_treatment_section
            ShortPlan of Treatment Section
            Control0..1
            Must Supporttrue
            LabelPlan of Treatment Section
            104. Composition.section:plan_of_treatment_section.title
            Shorttitle
            Control1..?
            Must Supporttrue
            106. Composition.section:plan_of_treatment_section.code
            ShortPlan of Treatment
            Control1..?
            Must Supporttrue
            LabelPlan of Treatment
            Pattern Value{
              "coding" : [{
                "system" : "http://loinc.org",
                "code" : "18776-5"
              }]
            }
            108. Composition.section:plan_of_treatment_section.text
            Shorttext
            Control1..?
            Must Supporttrue
            110. Composition.section:plan_of_treatment_section.entry
            Shortentry
            Must Supporttrue
            SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • profile @ resolve()
            • 112. Composition.section:plan_of_treatment_section.entry:sliceEntry
              Slice NamesliceEntry
              ShortThis section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
              TypeReference(US Core Goal Profile, US Core MedicationRequest Profile, US Core Encounter Profile, Communication, Appointment, CommunicationRequest, DeviceRequest, NutritionOrder, Task, ServiceRequest, VisionPrescription, RequestGroup)
              114. Composition.section:planned_procedure_section
              Slice Nameplanned_procedure_section
              ShortPlanned Procedure Section
              Control0..1
              Must Supporttrue
              LabelPlanned Procedure Section
              116. Composition.section:planned_procedure_section.title
              Shorttitle
              Control1..?
              Must Supporttrue
              118. Composition.section:planned_procedure_section.code
              ShortPlanned Procedure
              Control1..?
              Must Supporttrue
              LabelPlanned Procedure
              Pattern Value{
                "coding" : [{
                  "system" : "http://loinc.org",
                  "code" : "59772-4"
                }]
              }
              120. Composition.section:planned_procedure_section.text
              Shorttext
              Control1..?
              Must Supporttrue
              122. Composition.section:planned_procedure_section.entry
              Shortentry
              SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • profile @ resolve()
              • 124. Composition.section:planned_procedure_section.entry:planned_procedure_entry
                Slice Nameplanned_procedure_entry
                ShortThis section contains unprofiled resources not covered by US Core. Please refer to C-CDA R2.1 for guidance on terminology, etc.
                TypeReference(ServiceRequest)
                Must Supporttrue
                126. Composition.section:procedure_disposition_section
                Slice Nameprocedure_disposition_section
                ShortProcedure Disposition Section
                Control0..1
                Must Supporttrue
                LabelProcedure Disposition Section
                128. Composition.section:procedure_disposition_section.title
                Shorttitle
                Control1..?
                Must Supporttrue
                130. Composition.section:procedure_disposition_section.code
                ShortProcedure Disposition
                Control1..?
                Must Supporttrue
                LabelProcedure Disposition
                Pattern Value{
                  "coding" : [{
                    "system" : "http://loinc.org",
                    "code" : "59775-7"
                  }]
                }
                132. Composition.section:procedure_disposition_section.text
                ShortThis section contains only human readable content
                Control1..?
                Must Supporttrue
                134. Composition.section:procedure_indications_section
                Slice Nameprocedure_indications_section
                ShortProcedure Indications Section
                Control0..1
                Must Supporttrue
                LabelProcedure Indications Section
                136. Composition.section:procedure_indications_section.title
                Shorttitle
                Control1..?
                Must Supporttrue
                138. Composition.section:procedure_indications_section.code
                ShortProcedure Indications
                Control1..?
                Must Supporttrue
                LabelProcedure Indications
                Pattern Value{
                  "coding" : [{
                    "system" : "http://loinc.org",
                    "code" : "59768-2"
                  }]
                }
                140. Composition.section:procedure_indications_section.text
                ShortThis section contains only human readable content
                Control1..?
                Must Supporttrue
                142. Composition.section:procedure_indications_section.entry
                Shortentry
                SlicingThis element introduces a set of slices on Composition.section.entry. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • profile @ resolve()
                • 144. Composition.section:procedure_indications_section.entry:problem_entry
                  Slice Nameproblem_entry
                  TypeReference(US Core Condition Profile)
                  Must Supporttrue
                  146. Composition.section:procedure_implants_section
                  Slice Nameprocedure_implants_section
                  ShortProcedure Implants Section
                  Control0..1
                  Must Supporttrue
                  LabelProcedure Implants Section
                  148. Composition.section:procedure_implants_section.title
                  Shorttitle
                  Control1..?
                  Must Supporttrue
                  150. Composition.section:procedure_implants_section.code
                  ShortProcedure Implants
                  Control1..?
                  Must Supporttrue
                  LabelProcedure Implants
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://loinc.org",
                      "code" : "59771-6"
                    }]
                  }
                  152. Composition.section:procedure_implants_section.text
                  ShortThis section contains only human readable content
                  Control1..?
                  Must Supporttrue
                  154. Composition.section:surgical_drains_section
                  Slice Namesurgical_drains_section
                  ShortSurgical Drains Section
                  Control0..1
                  Must Supporttrue
                  LabelSurgical Drains Section
                  156. Composition.section:surgical_drains_section.title
                  Shorttitle
                  Control1..?
                  Must Supporttrue
                  158. Composition.section:surgical_drains_section.code
                  ShortSurgical Drains
                  Control1..?
                  Must Supporttrue
                  LabelSurgical Drains
                  Pattern Value{
                    "coding" : [{
                      "system" : "http://loinc.org",
                      "code" : "11537-8"
                    }]
                  }
                  160. Composition.section:surgical_drains_section.text
                  ShortThis section contains only human readable content
                  Control1..?
                  Must Supporttrue