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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="20121221012613" />
<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="33" 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>Lary</given>
<given></given>
<family>Byrd</family>
</name>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" displayName="Male" />
<birthTime value="19670518" />
</patient>
</patientRole>
</recordTarget>
<!-- The author of the report is the surgeon or physician who performed the procedure. -->
<author>
<time value="20121221012613" />
<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>Gastroenterology</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="20121221012613" />
<signatureCode code="S" />
<assignedEntity>
<id extension="999999999" root="2.16.840.1.113883.4.6" />
<addr nullFlavor="NI" />
<telecom nullFlavor="NI" />
<assignedPerson>
<name>
<given>Gastroenterology</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="45378" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT-4" displayName="Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)" />
<effectiveTime>
<low value="20121221" />
<high value="20121221" />
</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="20121221" />
<high value="20121221" />
</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>Gastroenterology</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>Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) (45378)</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Surgeon</title>
<text>
<list>
<item>Gastroenterology Surgery, MD</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Date of surgery</title>
<text>
<list>
<item>Thursday, December 20, 2012</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>Internal hemorrhoids without mention of complication (455.0)</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="455.0" displayName="Internal hemorrhoids without mention of complication" 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>Internal hemorrhoids without mention of complication (455.0)</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="455.0" displayName="Internal hemorrhoids without mention of complication" 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>Class I. Normal healthy patient</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>Normal Colon</item>
<item>No Polyps</item>
<item>No signs of Cancer</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>Topical</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Position</title>
<text>
<list>
<item>Prone</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>Prepped and draped in standard sterile fashion</item>
</list>
</text>
</section>
</component>
<component>
<section>
<title>Pre-medication</title>
<text>
<list>
<item>Propofol given in divided doses and titrated to effect</item>
<item>Total dose of 400 mg Propofol</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>Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) (45378)</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="45378" displayName="Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)" codeSystem="2.16.840.1.113883.6.12" codeSystemName="CPT4" />
</act>
</entry>
<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>Olympus colonoscope used</item>
<item>Colonoscope inserted</item>
<item>Scope advanced through the colon</item>
<item>Scope advanced through sigmoid to the cecum</item>
<item>Colon examined </item>
<item>No Polyps found</item>
<item>Scope withdrawn and retroflexed in the rectum</item>
<item>Small internal hemorrhoids identified</item>
<item>Hemorrhoids removed</item>
<item>Time withdrawal</item>
<item>Over 10 minutes</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>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>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.</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 Gastroenterology Surgery, MD at 8:26 PM Thursday, December 20, 2012</item>
</list>
</text>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>