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<!-- 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="20130322145555" />
<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="123" 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>John</given>
<given></given>
<family>Wayne</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" />
<birthTime value="19650115" />
</patient>
</patientRole>
</recordTarget>
<!-- The author of the report is the surgeon or physician who performed the procedure. -->
<author>
<time value="20130322145555" />
<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 & Osteopathic Physicians" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>Ophthalmology</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="20130322145555" />
<signatureCode code="S" />
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>Ophthalmology</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="66984" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)" />
<effectiveTime>
<low value="20130322" />
<high value="20130322" />
</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="20130322" />
<high value="20130322" />
</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 & Osteopathic Physicians" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>Ophthalmology</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>Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) (66984)</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Surgeon</title>
<text>
<list>
<item>Ophthalmology Surgery, MD</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Date of surgery</title>
<text>
<list>
<item>Friday, March 22, 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>Nuclear sclerosis (366.16)</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="366.16" displayName="Nuclear sclerosis" 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>Nuclear sclerosis (366.16)</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="366.16" displayName="Nuclear sclerosis" 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>See diagnosis</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>See anesthesia report</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>No unusual findings</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>Monitored Anesthesia Care (MAC)</item>
<item>Topical</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>Operating microscope drawn into place</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Draping</title>
<text>
<list>
<item>Prepped and draped in standard sterile fashion</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Pre-medication</title>
<text>
<list>
<item>Not applicable</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>Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) (66984)</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="66984" displayName="Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4" />
</act>
</entry>
<component>
<section>
<title>Laterality</title>
<text>
<list>
<item>Bilateral</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>Lieberman lid speculum placed between eyelids</item>
<item>Superior temporal incision performed in beveled three-stage maneuver</item>
<item>3.0 mm keratome blade used</item>
<item>Watertight wound created</item>
<item>Intraocular nonpreserved lidocaine 0.2 cc used to complete anesthesia</item>
<item>Viscoelastic applied</item>
<item>Viscoelastic applied</item>
<item>Separate paracentesis site prepared in anticipation of two-handed phaco-technique</item>
<item>Continuous tear anterior capsulorrhexis performed with Utrata forceps</item>
<item>Hydrodissection completed</item>
<item>30-gauge cannula used on a syringe with balanced salt solution</item>
<item>Phacoemulsification performed by chop technique</item>
<item>Viscoelastic reapplied to anterior chamber every 10 units of CDE for 10.41 total units of energy</item>
<item>I&A used to remove remaining cortex</item>
<item>Posterior capsule polished under low vacuum</item>
<item>Posterior capsule remained clear and intact</item>
<item>SN60WF intraocular lens of 22.5 diopters in power inserted</item>
<item>Lens inserted through 2.4 mm incision into capsular bag</item>
<item>Lens rotated to achieve stability and centration</item>
<item>Residual viscoelastic removed with irrigation-aspiration tip</item>
<item>Miostat used to constrict pupil and hydrate wounds</item>
<item>Vigamox 0.1 cc injected intracamerally</item>
<item>Wound checked and watertight</item>
<item>Vigamox and Timolol applied topically to eye</item>
<item>Gentamycin ophthalmic ointment applied</item>
<item>Lid speculum removed</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>0 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>Home</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>Not applicable</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>None</item>
</list>
</text>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.22.2.37" />
<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>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Comments</title>
<text>
<list>
<item>Patient tolerated procedure well.
Follow up in 48 hours Patient to resume preoperative eye drops and oral medications</item>
</list>
</text>
</section>
</component>
</section>
</component>
<!-- Visual representation of document signatures. Also represented with legalAuthenticator above. -->
<component>
<section>
<title>Signature</title>
<text>
<list>
<item>Signed by Ophthalmology Surgery, MD at 10:55 AM Friday, March 22, 2013</item>
</list>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>