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<?xml-stylesheet type="text/xsl" href="./Content/xsl/CDA.xsl"?>
<!-- CCDA document implemented according to the implementation guide available at http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 
                 This document implements the operative note template, including all of its required sections and some of its optional sections.
                 Other structured fields from the operative report are implemented as simple sections without LOINC coding.
            -->
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="urn:hl7-org:v3 NIST_C32_schema/C32_CDA.xsd" xmlns="urn:hl7-org:v3" xmlns:sdtc="urn:hl7-org:sdtc">
  <realmCode code="US" />
  <typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040" />
  <!-- US General Header Template -->
  <templateId root="2.16.840.1.113883.10.20.22.1.1" />
  <!-- Operative Note template  -->
  <templateId root="2.16.840.1.113883.10.20.22.1.7" />
  <id extension="TT988" root="2.16.840.1.113883.19.5.99999.1" />
  <code codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" code="11504-8" displayName="Surgical Operation Note" />
  <title>Operative Report</title>
  <effectiveTime value="20130625173943" />
  <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25" />
  <languageCode code="en-US" />
  <setId extension="sTT988" root="2.16.840.1.113883.19.5.99999.19" />
  <versionNumber value="1" />
  <!-- recordTarget includes the patient identifiers. -->
  <recordTarget>
    <patientRole>
      <id extension="1" root="2.16.840.1.113883.19.5.99999.2" />
      <!-- MRN ID using HL7 example OID. -->
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <patient>
        <name use="L">
          <!-- L is "Legal" from HL7 EntityNameUse 2.16.840.1.113883.5.45 -->
          <given>Dee</given>
          <given></given>
          <family>Fault</family>
        </name>
        <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" displayName="Female" />
        <birthTime value="19600101" />
      </patient>
    </patientRole>
  </recordTarget>
  <!-- The author of the report is the surgeon or physician who performed the procedure. -->
  <author>
    <time value="20130625173943" />
    <assignedAuthor>
      <id extension="99999999" root="2.16.840.1.113883.4.6" />
      <!-- General NUCC code for physicians. This could be narrowed by specialty. -->
      <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians" />
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <assignedPerson>
        <name>
          <given>General</given>
          <family>Surgery</family>
        </name>
      </assignedPerson>
    </assignedAuthor>
  </author>
  <!-- The custodian is the institution where the procedure was performed. -->
  <custodian>
    <assignedCustodian>
      <representedCustodianOrganization>
        <id extension="99999999" root="2.16.840.1.113883.4.6" />
        <name>Default Center</name>
        <telecom nullFlavor="NI" />
        <addr nullFlavor="NI" />
      </representedCustodianOrganization>
    </assignedCustodian>
  </custodian>
  <!-- If the report is signed out, the legal authenticator is the surgeon. If the report is not signed out,
                     then the legalAuthenticator element is absent. -->
  <legalAuthenticator>
    <time value="20130625173943" />
    <signatureCode code="S" />
    <assignedEntity>
      <id extension="999999999" root="2.16.840.1.113883.4.6" />
      <addr nullFlavor="NI" />
      <telecom nullFlavor="NI" />
      <assignedPerson>
        <name>
          <given>General</given>
          <family>Surgery</family>
        </name>
      </assignedPerson>
    </assignedEntity>
  </legalAuthenticator>
  <!-- We are documenting a surgical procedure, which is represented as a serviceEvent with CPT-4 code. 
                     If multiple procedures were performed, documntationOf is repeated for each with a separate CPT
                     code in each serviceEvent. -->
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="PCPR">
      <code code="38792" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Injection procedure; radioactive tracer for identification of sentinel node" />
      <effectiveTime>
        <low value="20130625" />
        <high value="20130625" />
      </effectiveTime>
      <performer typeCode="PPRF">
        <functionCode code="PP" displayName="Primary Performer" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
          <originalText>Surgeon</originalText>
        </functionCode>
        <time>
          <low value="20130625" />
          <high value="20130625" />
        </time>
        <assignedEntity>
          <id extension="999999999" root="2.16.840.1.113883.4.6" />
          <!-- General NUCC code for physicians. This could be narrowed by specialty. -->
          <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians" />
          <addr nullFlavor="NI" />
          <telecom nullFlavor="NI" />
          <assignedPerson>
            <name>
              <given>General</given>
              <family>Surgery</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="PCPR">
      <code code="38525" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Biopsy or excision of lymph node(s); open, deep axillary node(s)" />
      <effectiveTime>
        <low value="20130625" />
        <high value="20130625" />
      </effectiveTime>
      <performer typeCode="PPRF">
        <functionCode code="PP" displayName="Primary Performer" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
          <originalText>Surgeon</originalText>
        </functionCode>
        <time>
          <low value="20130625" />
          <high value="20130625" />
        </time>
        <assignedEntity>
          <id extension="999999999" root="2.16.840.1.113883.4.6" />
          <!-- General NUCC code for physicians. This could be narrowed by specialty. -->
          <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians" />
          <addr nullFlavor="NI" />
          <telecom nullFlavor="NI" />
          <assignedPerson>
            <name>
              <given>General</given>
              <family>Surgery</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <documentationOf typeCode="DOC">
    <serviceEvent classCode="PCPR">
      <code code="19301" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);" />
      <effectiveTime>
        <low value="20130625" />
        <high value="20130625" />
      </effectiveTime>
      <performer typeCode="PPRF">
        <functionCode code="PP" displayName="Primary Performer" codeSystem="2.16.840.1.113883.12.443" codeSystemName="Provider Role">
          <originalText>Surgeon</originalText>
        </functionCode>
        <time>
          <low value="20130625" />
          <high value="20130625" />
        </time>
        <assignedEntity>
          <id extension="999999999" root="2.16.840.1.113883.4.6" />
          <!-- General NUCC code for physicians. This could be narrowed by specialty. -->
          <code code="200000000X" codeSystem="2.16.840.1.113883.6.101" displayName="Allopathic &amp; Osteopathic Physicians" />
          <addr nullFlavor="NI" />
          <telecom nullFlavor="NI" />
          <assignedPerson>
            <name>
              <given>General</given>
              <family>Surgery</family>
            </name>
          </assignedPerson>
        </assignedEntity>
      </performer>
    </serviceEvent>
  </documentationOf>
  <!-- Operative Note uses a structuredBody to represent discrete data in the document. -->
  <component>
    <structuredBody>
      <!-- Initial summary sections including date, staff, procedures, diagnoses. -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.7.14" />
          <code code="10223-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Surgical operation note surgical procedure" />
          <title>Operations Performed</title>
          <text>
            <list>
              <item>Injection procedure; radioactive tracer for identification of sentinel node (38792)</item>
              <item>Biopsy or excision of lymph node(s); open, deep axillary node(s) (38525)</item>
              <item>Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); (19301)</item>
            </list>
          </text>
        </section>
      </component>
      <component>
        <section>
          <title>Surgeon</title>
          <text>
            <list>
              <item>General Surgery, MD</item>
            </list>
          </text>
        </section>
      </component>
      <component>
        <section>
          <title>Assistants</title>
          <text>
            <list>
              <item>Neuro Surgery, MD</item>
            </list>
          </text>
        </section>
      </component>
      <component>
        <section>
          <title>Date of surgery</title>
          <text>
            <list>
              <item>Tuesday, June 25, 2013</item>
            </list>
          </text>
        </section>
      </component>
      <!-- Preoperative and postoperative diagnosis sections are entry-level but using ICD-9 since that is what is available in production right now. -->
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.34" />
          <code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="SURGICAL OPERATION NOTE PREOPERATIVE DX" />
          <title>Preoperative Diagnosis</title>
          <text>
            <list>
              <item>Malignant neoplasm of upper-inner quadrant of female breast (174.2)</item>
            </list>
          </text>
          <entry>
            <act moodCode="EVN" classCode="ACT">
              <templateId root="2.16.840.1.113883.10.20.22.4.65" />
              <!-- ** Preoperative Diagnosis Entry ** -->
              <code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Preoperative Diagnosis" />
              <entryRelationship typeCode="SUBJ">
                <!-- Problem Observation template -->
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.4" />
                  <id nullFlavor="UNK" />
                  <code code="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
                  <statusCode code="completed" />
                  <!-- ICD-9-CM is available -->
                  <value nullFlavor="OTH" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:type="CD">
                    <translation code="174.2" displayName="Malignant neoplasm of upper-inner quadrant of female breast" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9-CM" />
                  </value>
                </observation>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <templateId root="2.16.840.1.113883.10.20.22.2.35" />
          <code code="10218-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Postoperative Diagnosis" />
          <title>Postoperative Diagnosis</title>
          <text>
            <list>
              <item>Malignant neoplasm of upper-inner quadrant of female breast (174.2)</item>
            </list>
          </text>
          <entry>
            <act moodCode="EVN" classCode="ACT">
              <templateId root="2.16.840.1.113883.10.20.22.4.65" />
              <!-- ** Preoperative Diagnosis Entry ** -->
              <code code="10219-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Preoperative Diagnosis" />
              <entryRelationship typeCode="SUBJ">
                <!-- Problem Observation template -->
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.22.4.4" />
                  <id nullFlavor="UNK" />
                  <code code="282291009" displayName="Diagnosis" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" />
                  <statusCode code="completed" />
                  <!-- ICD-9-CM is available -->
                  <value nullFlavor="OTH" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:type="CD">
                    <translation code="174.2" displayName="Malignant neoplasm of upper-inner quadrant of female breast" codeSystem="2.16.840.1.113883.6.103" codeSystemName="ICD-9-CM" />
                  </value>
                </observation>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <!-- Indications gets its own logical separation in the document with a single sub-section. -->
      <component>
        <section>
          <title>Indications for Surgery</title>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.10.20.22.2.29" />
              <code code="59768-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE INDICATIONS" />
              <title>Indications</title>
              <text>
                <list>
                  <item>Biopsy proven malignancy</item>
                </list>
              </text>
            </section>
          </component>
        </section>
      </component>
      <!-- Risk and consent is a logical section of the document with subsections for different aspects of risk documentation. -->
      <component>
        <section>
          <title>Risk and Consent</title>
          <component>
            <section>
              <title>Risk Factors</title>
              <text>
                <list>
                  <item>None</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>ASA Physical Status</title>
              <text>
                <list>
                  <item>Class II.  Patient with mild systemic disease</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Informed Consent</title>
              <text>
                <list>
                  <item>Yes: Indications for surgical procedure, risks, benefits, possible complications explained to patient including alternatives in treatment.  Patient had the chance to ask questions and all were answered to their satisfaction.  Patient understood and gave consent.</item>
                </list>
              </text>
            </section>
          </component>
        </section>
      </component>
      <!-- Operative findings gets its own logical separation in the document with a single sub-section. -->
      <component>
        <section>
          <title>Operative Findings</title>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.10.20.22.2.28" />
              <code code="59776-5" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE FINDINGS" />
              <title>Operative Findings</title>
              <text>
                <list>
                  <item>Palpable mass excised with grossly clear margins, confirmed by pathology</item>
                  <item>Sentinel node negative by frozen section</item>
                </list>
              </text>
            </section>
          </component>
        </section>
      </component>
      <!-- Preparation is a logical section of the document with subsections for different items. -->
      <component>
        <section>
          <title>Preparation</title>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.10.20.22.2.25" />
              <code code="59774-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Procedure anesthesia" />
              <title>Anesthesia</title>
              <text>
                <list>
                  <item>General</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Position</title>
              <text>
                <list>
                  <item>Supine</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Surgical Field</title>
              <text>
                <list>
                  <item>Antiseptic applied</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Draping</title>
              <text>
                <list>
                  <item>Appropriate draping</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Pre-medication</title>
              <text>
                <list>
                  <item>Antibiotic</item>
                </list>
              </text>
            </section>
          </component>
        </section>
      </component>
      <!-- Operative description is challenging with the current specification, which calls for a single operative description 
                             field. In mTuitive's production application, each procedure documented in serviceEvent elements requires an operative 
                             description, and conditionally a laterality section.  We've made a single container operative description section 
                             containing subsections for each serviceEvent, which in turn have subsections for their own operative description and 
                             laterality fields.  Each procedure's container section contains a Procedure Context template which appropriately sets
                             sets the context for subsections in its scope.
                        -->
      <component>
        <section>
          <title>Operative Description</title>
          <component>
            <section>
              <title>Injection procedure; radioactive tracer for identification of sentinel node (38792)</title>
              <entry>
                <!-- We want to scope this section to the procedure that its subsections are documenting. -->
                <act moodCode="EVN" classCode="ACT">
                  <templateId root="2.16.840.1.113883.10.20.6.2.5" />
                  <!-- Procedure Context template to let us know exactly which procedure the sections in this scope document.-->
                  <code code="38792" displayName="Injection procedure; radioactive tracer for identification of sentinel node" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4" />
                </act>
              </entry>
              <component>
                <section>
                  <title>Laterality</title>
                  <text>
                    <list>
                      <item>Right</item>
                    </list>
                  </text>
                </section>
              </component>
              <component>
                <section>
                  <templateId root="2.16.840.1.113883.10.20.22.2.27" />
                  <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DESCRIPTION" />
                  <title>Operation Description</title>
                  <text>
                    <list>
                      <item>5cc of lymphazurin injected into subareolar position and massaged for 5 minutes</item>
                    </list>
                  </text>
                </section>
              </component>
            </section>
          </component>
          <component>
            <section>
              <title>Biopsy or excision of lymph node(s); open, deep axillary node(s) (38525)</title>
              <entry>
                <!-- We want to scope this section to the procedure that its subsections are documenting. -->
                <act moodCode="EVN" classCode="ACT">
                  <templateId root="2.16.840.1.113883.10.20.6.2.5" />
                  <!-- Procedure Context template to let us know exactly which procedure the sections in this scope document.-->
                  <code code="38525" displayName="Biopsy or excision of lymph node(s); open, deep axillary node(s)" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4" />
                </act>
              </entry>
              <component>
                <section>
                  <title>Laterality</title>
                  <text>
                    <list>
                      <item>Right</item>
                    </list>
                  </text>
                </section>
              </component>
              <component>
                <section>
                  <templateId root="2.16.840.1.113883.10.20.22.2.27" />
                  <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DESCRIPTION" />
                  <title>Operation Description</title>
                  <text>
                    <list>
                      <item>Wound infiltrated with local anesthetic</item>
                      <item>Appropriate dressing applied</item>
                      <item>Incision made in the usual and sterile fashion</item>
                      <item>Tissue dissected to node</item>
                      <item>Node removed</item>
                      <item>No other blue-stained nodes noted</item>
                      <item>No suspicious or palpable nodes noted</item>
                      <item>Wound closed in layers</item>
                    </list>
                  </text>
                </section>
              </component>
            </section>
          </component>
          <component>
            <section>
              <title>Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); (19301)</title>
              <entry>
                <!-- We want to scope this section to the procedure that its subsections are documenting. -->
                <act moodCode="EVN" classCode="ACT">
                  <templateId root="2.16.840.1.113883.10.20.6.2.5" />
                  <!-- Procedure Context template to let us know exactly which procedure the sections in this scope document.-->
                  <code code="19301" displayName="Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4" />
                </act>
              </entry>
              <component>
                <section>
                  <title>Laterality</title>
                  <text>
                    <list>
                      <item>Right</item>
                    </list>
                  </text>
                </section>
              </component>
              <component>
                <section>
                  <templateId root="2.16.840.1.113883.10.20.22.2.27" />
                  <code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DESCRIPTION" />
                  <title>Operation Description</title>
                  <text>
                    <list>
                      <item>Natural skin line incision performed</item>
                      <item>Flaps were raised</item>
                      <item>Mass excised with appropriate margins</item>
                      <item>Tumor bed marked with radiographic clips</item>
                      <item>Hemostasis assured</item>
                      <item>Wound irrigated</item>
                      <item>Wound infiltrated with local anesthetic</item>
                      <item>Incision closed in layers</item>
                      <item>Appropriate dressing applied</item>
                    </list>
                  </text>
                </section>
              </component>
            </section>
          </component>
        </section>
      </component>
      <!-- Discharge and condition is a logical section of the document containing various subsections relating to the 
                             patient's condition and followup. -->
      <component>
        <section>
          <title>Discharge and Condition</title>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.10.20.18.2.9" />
              <code code="59770-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE ESTIMATED BLOOD LOSS" />
              <title>Estimated blood loss</title>
              <text>
                <list>
                  <item>25 mL or less</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Sponge/needle/instrument count</title>
              <text>
                <list>
                  <item>Correct x 2</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>Discharge</title>
              <text>
                <list>
                  <item>Surgical day care recovery</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.10.20.18.2.12" />
              <code code="59775-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DISPOSITION" />
              <title>Condition</title>
              <text>
                <list>
                  <item>Stable</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <title>DVT Prophylaxis</title>
              <text>
                <list>
                  <item>Anti Embolism Stockings (TED Stockings)</item>
                </list>
              </text>
            </section>
          </component>
          <component>
            <section>
              <templateId root="2.16.840.1.113883.10.20.22.2.31" />
              <code code="59773-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE SPECIMENS TAKEN" />
              <title>Specimen</title>
              <text>
                <list>
                  <item>Sentinel node, negative on frozen section</item>
                  <item>Lumpectomy specimen oriented for margins</item>
                </list>
              </text>
            </section>
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              <code code="55109-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complications" />
              <title>Complications</title>
              <text>
                <list>
                  <item>No complications</item>
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            <section>
              <title>Comments</title>
              <text>
                <list>
                  <item>Patient tolerated procedure well.</item>
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        </section>
      </component>
      <!-- Visual representation of document signatures.  Also represented with legalAuthenticator above. -->
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        <section>
          <title>Signature</title>
          <text>
            <list>
              <item>Signed by General Surgery, MD at 1:39 PM Tuesday, June 25, 2013</item>
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