Template 2.16.840.1.113883.10.20.22.1.7 Operative Note

2012‑01‑12

Template 2.16.840.1.113883.10.20.22.1.7 - OperativeNote
Id 2.16.840.1.113883.10.20.22.1.7
Classification cdadocumentlevel
Context Pathname cda:ClinicalDocument
Label conf‑749
Version valid from 2012‑01‑12 status draft
Description The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies.
The Operative Note or Report is created immediately following a surgical or other high-risk procedure and records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.
Item DT Card Conf Desc Label
cda:ClinicalDocument
conf-749
treetree cda:templateId
II 1..1 M conf‑9914
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.1
treetree cda:templateId
II 1..1 M conf‑8483
treeblank treetree @root
1..1 F 2.16.840.1.113883.10.20.22.1.7
treetree cda:code
1..1 M conf‑8484
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.11.20.1.1 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.11.20.1.1"
treetree cda:documentationOf
1..* M Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF). conf‑8486
treeblank treetree cda:serviceEvent
1..1 M conf‑8493
Schematron assert Role red error
Test cda:code[@codeSystem='2.16.840.1.113883.6.96' or @codeSystem='2.16.840.1.113883.6.12' or @codeSystem='2.16.840.1.113883.6.104']
Message
i. The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD9 CM Procedures (CodeSystem 2.16.840.1.113883.6.104), CPT-4 (CodeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (CodeSystem 2.16.840.1.113883.6.96) ValueSet Procedure 2.16.840.1.113883.3.88.12.80.28 DYNAMIC
treeblank treeblank treetree cda:effectiveTime
IVL_TS 1..1 M conf‑8494
Schematron assert Role red error
Test string-length(@value)>=8 or (string-length(@value)<10 or ( string-length(@value)>=10 and (contains(@value,'+') or contains(@value,'-'))))
Message
The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.3)
Schematron assert Role red error
Test cda:low
Message
The serviceEvent/effectiveTime SHALL be present with effectiveTime/low.
Schematron assert Role red error
Test count(cda:high | cda:width) = 1
Message
If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high
Schematron assert Role red error
Test count(cda:high | cda:width) = 1
Message
When only the date and the length of the procedure are known a width element SHALL be present and the serviceEvent/effectiveTime/high SHALL not be present
treeblank treeblank treetree cda:performer
1..1 M conf‑8489
treeblank treeblank treeblank treetree @typeCode
1..1 F PPRF
treeblank treeblank treeblank treetree cda:assignedEntity
1..1 M conf‑10917
treeblank treeblank treeblank treeblank treetree cda:code
CE 1..1 M conf‑8490
treeblank treeblank treeblank treeblank treeblank treetree @code
1..1
CONF
The value of @code shall be drawn from value set 2.16.840.1.113883.3.88.12.3221.4 flexibility dynamic
alert Error: Cannot find value set "2.16.840.1.113883.3.88.12.3221.4"
treetree cda:component
1..1 M An Operative Note can conform to CDA Level 1 (nonXMLBody), CDA Level 2 (structuredBody with sections that contain a narrative block), or CDA Level 3 (structuredBody containing sections that contain a narrative block and coded entries). In this template (templateId 2.16.840.1.113883.10.20.22.1.7), coded entries are optional
If structuredBody, the component/structuredBody SHALL conform to the section constraints below
conf‑9585
Schematron assert Role red error
Test count(//cda:structuredBody | //cda:nonXMLBody)=1
Message
An Operative Note can have either a structuredBody or a nonXMLBody