SGHI FHIR Profile Implementation Guide
0.1.0 - ci-build

SGHI FHIR Profile Implementation Guide, published by Kathurima Kimathi. 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/savannahghi/sil_fhir_profile_ig/ and changes regularly. See the Directory of published versions

StructureMap: Theatre Note Extraction

Official URL: https://fhir.slade360.co.ke/fhir/StructureMap/ExtractTheatreNote Version: 0.1.0
Active as of 2026-09-14 Computable Name: ExtractTheatreNote

A Procedure with the whole team as performers and the operator's description as its note. The procedure name travels as written rather than coded: theatre lists are not coded here, and a guessed SNOMED procedure code on an operation note is a claim about what was done to a patient – the one place in this set where being wrong is not a reporting problem.

/// url = 'https://fhir.slade360.co.ke/fhir/StructureMap/ExtractTheatreNote'
/// name = 'ExtractTheatreNote'
/// title = 'Theatre Note Extraction'
/// status = 'active'
/// description = 'A Procedure with the whole team as performers and the operator\'s description as its note. The procedure name travels as written rather than coded: theatre lists are not coded here, and a guessed SNOMED procedure code on an operation note is a claim about what was done to a patient -- the one place in this set where being wrong is not a reporting problem.'

uses "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse" alias QR as source
uses "http://hl7.org/fhir/StructureDefinition/Bundle" alias Bundle as target
uses "http://hl7.org/fhir/StructureDefinition/Observation" alias Observation as target
uses "http://hl7.org/fhir/StructureDefinition/Procedure" alias Procedure as target

group ExtractTheatreNote(source qr : QR, target bundle : Bundle) {
  qr -> bundle.type = 'transaction' "setBundleType";
  qr.item as g where (linkId = 'operation') then {
    g.item as it where ((linkId = 'operation/procedure') and answer.value.exists()) ->  bundle.entry as entry,  entry.resource = create('Procedure') as proc then {
      qr ->  proc,  entry then BuildProcedureBase(qr, proc, entry) "base";
      it -> proc.status = 'completed' "status";
      qr.encounter as e -> proc.encounter = e;
      it.answer first as a then {
        a.value as txt ->  proc.code as cc,  cc.text = txt "codeText";
      };
      g.item as at where ((linkId = 'operation/at') and answer.value.exists()) then {
        at.answer first as a then {
          a.value as v -> proc.occurrence = v "occurrence";
        };
      } "atRule";
      g.item as inc where ((linkId = 'operation/incision') and answer.value.exists()) then {
        inc.answer first as a then {
          a.value as txt ->  proc.note as n,  n.text = txt "incisionNote";
        };
      } "incisionRule";
      qr.item as d where ((linkId = 'description') and answer.value.exists()) then {
        d.answer first as a then {
          a.value as txt ->  proc.note as n,  n.text = txt "descriptionNote";
        };
      } "descriptionRule";
      // The whole team, each as a performer with the part they played. A note
      // that names only the surgeon cannot answer who assisted, which is the
      // question asked when a complication is reviewed.
      qr.item as t where (linkId = 'team') then {
        t.item as s where ((linkId = 'team/surgeon') and answer.value.exists()) then {
          s.answer first as a then {
            a.value as ref -> proc.performer as p then {
              ref -> p.actor = ref "actor";
              ref ->  p.function as fn,  fn.text = 'Surgeon' "function";
            } "performer";
          };
        } "surgeonRule";
        t.item as asst where ((linkId = 'team/assistant') and answer.value.exists()) then {
          asst.answer as a then {
            a.value as ref -> proc.performer as p then {
              ref -> p.actor = ref "actor";
              ref ->  p.function as fn,  fn.text = 'Assistant' "function";
            } "performer";
          } "answers";
        } "assistantRule";
        t.item as an where ((linkId = 'team/anaesthetist') and answer.value.exists()) then {
          an.answer first as a then {
            a.value as ref -> proc.performer as p then {
              ref -> p.actor = ref "actor";
              ref ->  p.function as fn,  fn.text = 'Anaesthetist' "function";
            } "performer";
          };
        } "anaesthetistRule";
      } "teamGroup";
    } "theatreProcedure";
  } "operationGroup";
  qr.item as g where (linkId = 'operation') then {
    g.item as it where ((linkId = 'operation/anaesthesia') and answer.value.exists()) ->  bundle.entry as entry,  entry.resource = create('Observation') as obs then {
      qr ->  obs,  entry then BuildObsBase(qr, obs, entry) "base";
      qr -> obs then SetSurveyCategory(qr, obs) "category";
      it -> obs.code as cc then {
        it -> cc.coding as cg then {
          it -> cg.system = 'https://fhir.slade360.co.ke/fhir/CodeSystem/concept-codesystem' "sys";
          it -> cg.code = 'anaesthesia-used-as-recorded-on-the-theatre-note' "cd";
          it -> cg.display = 'Anaesthesia used, as recorded on the theatre note' "dsp";
        } "coding";
      } "code";
      it.answer first as a then {
        a.value as txt ->  obs.note as n,  n.text = txt "text";
      };
    } "narr_anaesthesia_used_as_recorded_on_the_theatre_note";
  } "anaesthesiaGroup";
  qr.item as it where ((linkId = 'description') and answer.value.exists()) ->  bundle.entry as entry,  entry.resource = create('Observation') as obs then {
    qr ->  obs,  entry then BuildObsBase(qr, obs, entry) "base";
    qr -> obs then SetSurveyCategory(qr, obs) "category";
    it -> obs.code as cc then {
      it -> cc.coding as cg then {
        it -> cg.system = 'http://loinc.org' "sys";
        it -> cg.code = '11504-8' "cd";
        it -> cg.display = 'Surgical operation note' "dsp";
      } "coding";
      it -> cc.text = 'Description of the operation' "codeText";
    } "code";
    it.answer first as a then {
      a.value as txt ->  obs.note as n,  n.text = txt "text";
    };
  } "narr_11504_8";
}

// ─────────────────────────────────────────────────────────────────────────────
// Shared scaffolding. Repeated in each map rather than imported: the transform
// engine resolves `imports` against whatever StructureMaps happen to be on the
// server, and a form that stops extracting because a shared map was not
// uploaded is a worse failure than a duplicated group.
// Two notes on what the publisher's StructureMap validator says about this file.
// Source parameters below are left untyped on purpose. Writing `: Element` makes
// the validator compare QuestionnaireResponse.item against the literal 'Element'
// and report them as incompatible with each other, which is noise, not a finding.
// `evaluate(context, expression)` is flagged as "takes 1 parameter but 2 were
// found". Leave it. The FML parser in the same jar refuses the one-argument form
// outright -- it wants a parameter, a comma, then the FHIRPath -- so the
// publisher is objecting to what its own compiler emits. Two arguments is the
// only form that compiles, and it is what the R5 transform engine executes.
// ─────────────────────────────────────────────────────────────────────────────
group BuildObsBase(source qr : QR, target obs : Observation, target entry) {
  qr -> obs then SetResponseProvenance(qr, obs) "responseProvenance";
  qr -> obs.id = uuid() then SetObservationFullUrl(obs, entry) "idAndFullUrl";
  qr -> entry.request as request then {
    qr -> request.method = 'POST' "requestMethod";
    qr -> request.url = 'Observation' "requestUrl";
  } "entryRequest";
  qr -> obs.status = 'final' "status";
  qr.subject as s -> obs.subject = s;
  qr.encounter as e -> obs.encounter = e;
  qr.authored as t -> obs.effective = t "effective";
  qr.source as src -> obs.performer = src "performerFromSource";
  qr where (source.exists().not()) then {
    qr.author as a -> obs.performer = a "performerFromAuthor";
  } "performerFallback";
  // A stored response's id already reads "QuestionnaireResponse/<id>", so it is
  // a relative reference as it stands. The hasValue() guard is what stops an
  // unsaved response -- one posted straight to $extract rather than saved first
  // -- from writing "QuestionnaireResponse/null" into the record.
  qr.id as qid where ($this.hasValue()) ->  obs.derivedFrom = create('Reference') as ref,  ref.reference = qid "linkQuestionnaireResponse";
}

group SetObservationFullUrl(source obs : Observation, target entry) {
  obs.id as id -> entry.fullUrl = append('https://fhir.slade360.co.ke/fhir/Observation/', id) "assignFullUrl";
}

// The two answer shapes a component can carry. Both read the answer through the
// untyped `.value` accessor: reading `valueCoding` or `valueQuantity` by its
// typed property name fails at transform time on HAPI R5 with "Attempt to read
// invalid property ... on QuestionnaireResponse.item.answer".
group SetComponentCodedValue(source it, target comp) {
  it.answer first as a then {
    a.value as cv -> comp.value = create('CodeableConcept') as cc then {
      cv -> cc.coding = cv "valueCoding";
      cv.display as d -> cc.text = d "valueText";
    } "codedValue";
  } "componentAnswer";
}

group SetComponentValue(source it, target comp) {
  it.answer first as a then {
    a.value as v -> comp.value = v "plainValue";
  } "componentAnswer";
}

group SetSurveyCategory(source qr : QR, target obs : Observation) {
  qr -> obs.category as cat then {
    qr -> cat.coding as coding then {
      qr -> coding.system = 'http://terminology.hl7.org/CodeSystem/observation-category' "categorySystem";
      qr -> coding.code = 'survey' "categoryCode";
      qr -> coding.display = 'Survey' "categoryDisplay";
    } "categoryCoding";
  } "category";
}

group BuildProcedureBase(source qr : QR, target r : Procedure, target entry) {
  qr -> r then SetResponseProvenance(qr, r) "responseProvenance";
  qr -> r.id = uuid() then SetProcedureFullUrl(r, entry) "idAndFullUrl";
  qr -> entry.request as request then {
    qr -> request.method = 'POST' "requestMethod";
    qr -> request.url = 'Procedure' "requestUrl";
  } "entryRequest";
  // The response's own time, as a floor, the way BuildObsBase does it. A rule
  // that reads a time off the form overwrites this; without it a procedure whose
  // date column was taken off on review has no time at all, and a procedure with
  // no time cannot be ordered against the rest of the admission.
  qr.authored as t -> r.occurrence = t "occurrenceFallback";
  qr.subject as s -> r.subject = s;
}

group SetProcedureFullUrl(source r : Procedure, target entry) {
  r.id as id -> entry.fullUrl = append('https://fhir.slade360.co.ke/fhir/Procedure/', id) "assignFullUrl";
}

// ── Provenance and tenancy ───────────────────────────────────────────────────
// Two tags on everything this map creates. The first says which questionnaire
// produced it, so a form that reopens mid-admission recalls its own earlier
// entries and not another form's. The second copies the tenant tags off the
// response, because nothing else on the path puts them there.
// The code is the form's document type, not the questionnaire's id: every
// environment mints its own ids, and there is only one set of maps, so an id
// here would tie the tag to whichever environment stamped it.
// ── Provenance and tenancy ───────────────────────────────────────────────────
group SetResponseProvenance(source qr : QR, target r) {
  qr -> r.meta as m then {
    qr -> m.tag as t then {
      qr -> t.system = 'http://slade360edi.com/questionnaire-provenance' "provenanceSystem";
      qr -> t.code = 'theatre-note' "provenanceCode";
      qr -> t.display = 'Theatre note' "provenanceDisplay";
    } "provenanceTag";
  } "provenanceMeta";
  // Every tag the response carries, onto the resource. `meta` is 0..1, so this
  // lands on the same meta the rule above created rather than a second one.
  qr.meta as qm then {
    qm.tag as qt ->  r.meta as m,  m.tag = qt "copyTag";
  } "tenantTags";
}