{ "resourceType" : "Procedure", "id" : "procedure-single-example", "meta" : { "profile" : ["https://fhir.doh.gov.ph/phcore/StructureDefinition/ph-core-procedure"] }, "language" : "en", "text" : { "status" : "generated", "div" : "

Generated Narrative: Procedure procedure-single-example

Profile: PH Core Procedure

identifier: DOHProcedureID/PROC-2024-000123\u00a0(use:\u00a0usual,\u00a0), PhilHealthProcedureID/PH-APP-789456\u00a0(use:\u00a0secondary,\u00a0)

basedOn: ServiceRequest for emergency appendectomy

partOf: Episode of care for acute abdomen treatment

status: Completed

statusReason: Successful

category: Surgical procedure

code: Laparoscopic appendectomy

subject: Juan Jane Dela Fuente Dela Cruz Male, DoB: 1980-01-01 ( http://philhealth.gov.ph/fhir/Identifier/philhealth-id#PhilHealthID#63-584789845-5)

encounter: Encounter: identifier = http://example.org/encounter-id#ENC-12345; status = finished; class = ambulatory (ActCode#AMB); type = ambulatory; period = 2023-01-01 10:00:00+0000 --> 2023-01-01 11:00:00+0000

performed: 2024-01-15 08:30:00+0800 --> 2024-01-15 10:15:00+0800

recorder: Practitioner Maria Clara Santos (official)

asserter: RelatedPerson Maria Cruz Santos(official)

performer

function: Healthcare professional

actor: Practitioner Maria Clara Santos (official)

onBehalfOf: Organization Department of Health - Sattelite Office

performer

function: Caregiver

actor: RelatedPerson Maria Cruz Santos(official)

reasonCode: Acute appendicitis with peritonitis

reasonReference: Condition Diabetes mellitus type 2

bodySite: Right lower quadrant abdomen

outcome: Procedure completed without complications

followUp: Follow-up visit in 7 days for wound check

note: @2024-01-15 10:30:00+0800

Patient tolerated procedure well. Minimal blood loss. Appendix was inflamed but intact. No perforation noted.

\n

usedCode: Laparoscopic instruments

" }, "identifier" : [{ "use" : "usual", "system" : "https://fhir.doh.gov.ph/phcore/NamingSystem/procedure-id", "value" : "PROC-2024-000123" }, { "use" : "secondary", "system" : "http://philhealth.gov.ph/procedure", "value" : "PH-APP-789456" }], "basedOn" : [{ "display" : "ServiceRequest for emergency appendectomy" }], "partOf" : [{ "display" : "Episode of care for acute abdomen treatment" }], "status" : "completed", "statusReason" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "385669000", "display" : "Successful" }] }, "category" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "387713003", "display" : "Surgical procedure" }] }, "code" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "80146002", "display" : "Appendectomy" }], "text" : "Laparoscopic appendectomy" }, "subject" : { "reference" : "Patient/patient-single-example" }, "encounter" : { "reference" : "Encounter/encounter-single-example" }, "performedPeriod" : { "start" : "2024-01-15T08:30:00+08:00", "end" : "2024-01-15T10:15:00+08:00" }, "recorder" : { "reference" : "Practitioner/practitioner-single-example" }, "asserter" : { "reference" : "RelatedPerson/relatedperson-single-example" }, "performer" : [{ "function" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "223366009", "display" : "Healthcare professional" }] }, "actor" : { "reference" : "Practitioner/practitioner-single-example" }, "onBehalfOf" : { "reference" : "Organization/organization-single-example" } }, { "function" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "133932002", "display" : "Caregiver" }] }, "actor" : { "reference" : "RelatedPerson/relatedperson-single-example" } }], "reasonCode" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "74400008", "display" : "Appendicitis" }], "text" : "Acute appendicitis with peritonitis" }], "reasonReference" : [{ "reference" : "Condition/condition-single-example" }], "bodySite" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "66754008", "display" : "Appendix structure" }], "text" : "Right lower quadrant abdomen" }], "outcome" : { "coding" : [{ "system" : "http://snomed.info/sct", "code" : "385669000", "display" : "Successful" }], "text" : "Procedure completed without complications" }, "followUp" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "226007004", "display" : "Post-surgical wound care" }], "text" : "Follow-up visit in 7 days for wound check" }], "note" : [{ "time" : "2024-01-15T10:30:00+08:00", "text" : "Patient tolerated procedure well. Minimal blood loss. Appendix was inflamed but intact. No perforation noted." }], "usedCode" : [{ "coding" : [{ "system" : "http://snomed.info/sct", "code" : "261424001", "display" : "Primary operation" }], "text" : "Laparoscopic instruments" }] }