Draft PH Core Implementation Guide, published by UP Manila National TeleHealth Center. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/UP-Manila-SILab/ph-core/ and changes regularly. See the Directory of published versions

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: procedure-single-example - XML Representation

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<Procedure xmlns="http://hl7.org/fhir">
  <id value="procedure-single-example"/>
  <meta>
    <profile
             value="http://doh.gov.ph/fhir/ph-core/StructureDefinition/ph-core-procedure"/>
  </meta>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p><b>Procedure:</b> Laparoscopic appendectomy (SNOMED CT: 80146002)</p><p><b>Subject:</b> Juan Dela Cruz</p><p><b>Status:</b> Completed</p><p><b>Performed:</b> January 15, 2024, 08:30 - 10:15 (Asia/Manila)</p><p><b>Performer:</b> Dr. Maria Clara Santos (Healthcare professional) on behalf of Department of Health - Central Office</p><p><b>Reason:</b> Acute appendicitis with peritonitis (SNOMED CT: 74400008)</p><p><b>Body Site:</b> Entire appendix - Right lower quadrant abdomen</p><p><b>Outcome:</b> Successful - Procedure completed without complications</p><p><b>Follow-up:</b> Postsurgical wound care in 7 days</p><p><b>Notes:</b> Patient tolerated procedure well. Minimal blood loss. Appendix was inflamed but intact.</p></div>
  </text>
  <identifier>
    <use value="usual"/>
    <system value="http://doh.gov.ph/fhir/ph-core/NamingSystem/procedure-id"/>
    <value value="PROC-2024-000123"/>
  </identifier>
  <identifier>
    <use value="secondary"/>
    <system value="http://philhealth.gov.ph/procedure"/>
    <value value="PH-APP-789456"/>
  </identifier>
  <basedOn>
    <display value="ServiceRequest for emergency appendectomy"/>
  </basedOn>
  <partOf>
    <display value="Episode of care for acute abdomen treatment"/>
  </partOf>
  <status value="completed"/>
  <statusReason>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="281501002"/>
      <display value="Procedure carried out successfully"/>
    </coding>
  </statusReason>
  <category>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="387713003"/>
      <display value="Surgical procedure"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="80146002"/>
      <display value="Appendectomy"/>
    </coding>
    <text value="Laparoscopic appendectomy"/>
  </code>
  <subject>🔗 
    <reference value="Patient/patient-single-example"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/encounter-single-example"/>
  </encounter>
  <performedPeriod>
    <start value="2024-01-15T08:30:00+08:00"/>
    <end value="2024-01-15T10:15:00+08:00"/>
  </performedPeriod>
  <recorder>🔗 
    <reference value="Practitioner/practitioner-single-example"/>
  </recorder>
  <asserter>🔗 
    <reference value="RelatedPerson/relatedperson-single-example"/>
  </asserter>
  <performer>
    <function>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="223366009"/>
        <display value="Healthcare professional"/>
      </coding>
    </function>
    <actor>🔗 
      <reference value="Practitioner/practitioner-single-example"/>
    </actor>
    <onBehalfOf>🔗 
      <reference value="Organization/organization-single-example"/>
    </onBehalfOf>
  </performer>
  <performer>
    <function>
      <coding>
        <system value="http://snomed.info/sct"/>
        <code value="133932002"/>
        <display value="Caregiver"/>
      </coding>
    </function>
    <actor>🔗 
      <reference value="RelatedPerson/relatedperson-single-example"/>
    </actor>
  </performer>
  <reasonCode>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="74400008"/>
      <display value="Appendicitis"/>
    </coding>
    <text value="Acute appendicitis with peritonitis"/>
  </reasonCode>
  <reasonReference>🔗 
    <reference value="Condition/condition-single-example"/>
  </reasonReference>
  <bodySite>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="181250006"/>
      <display value="Entire appendix"/>
    </coding>
    <text value="Right lower quadrant abdomen"/>
  </bodySite>
  <outcome>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="385669000"/>
      <display value="Successful"/>
    </coding>
    <text value="Procedure completed without complications"/>
  </outcome>
  <complication>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="109721000"/>
      <display value="No complication"/>
    </coding>
  </complication>
  <followUp>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="18949003"/>
      <display value="Postsurgical wound care"/>
    </coding>
    <text value="Follow-up visit in 7 days for wound check"/>
  </followUp>
  <note>
    <time value="2024-01-15T10:30:00+08:00"/>
    <text
          value="Patient tolerated procedure well. Minimal blood loss. Appendix was inflamed but intact. No perforation noted."/>
  </note>
  <usedCode>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="363708005"/>
      <display value="Surgical instrument"/>
    </coding>
    <text value="Laparoscopic instruments"/>
  </usedCode>
</Procedure>