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pending Template  Operative Note

Template 2.16.840.1.113883.10.20.22.1.7 - OperativeNote
Id 2.16.840.1.113883.10.20.22.1.7
Version valid from 2013‑01‑31 status pending Under pre-publication review
Classification CDA Document Level Template
Context Pathname //
Open/Closed Open (other than defined elements are allowed)
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.
Used by / Uses
Used by / Uses 16 templates
Uses Template id as Name Version
2.16.840.1.113883.10.20.22.2.25 Containment AnesthesiaSection DYNAMIC
2.16.840.1.113883.10.20.22.2.37 Containment ComplicationsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.34 Containment PreoperativeDiagnosisSection DYNAMIC
2.16.840.1.113883.10.20.18.2.9 Containment ProcedureEstimatedBloodLossSection DYNAMIC
2.16.840.1.113883.10.20.22.2.28 Containment ProcedureFindingsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.31 Containment ProcedureSpecimensTakenSection DYNAMIC
2.16.840.1.113883.10.20.22.2.27 Containment ProcedureDescriptionSection DYNAMIC
2.16.840.1.113883.10.20.22.2.40 Containment ProcedureImplantsSection DYNAMIC
2.16.840.1.113883.10.20.7.12 Containment OperativeNoteFluidsSection DYNAMIC
2.16.840.1.113883.10.20.7.14 Containment OperativeNoteSurgicalProcedureSection DYNAMIC
2.16.840.1.113883.10.20.22.2.10 Containment PlanofCareSection DYNAMIC
2.16.840.1.113883.10.20.22.2.30 Containment PlannedProcedureSection DYNAMIC
2.16.840.1.113883.10.20.18.2.12 Containment ProcedureDispositionSection DYNAMIC
2.16.840.1.113883.10.20.22.2.29 Containment ProcedureIndicationsSection DYNAMIC
2.16.840.1.113883.10.20.7.13 Containment SurgicalDrainsSection DYNAMIC
2.16.840.1.113883.10.20.22.2.35 Containment PostoperativeDiagnosisSection DYNAMIC
Item DT Card Conf Description Label
cda:ClinicalDocument
A consent, if present, SHALL be represented as ClinicalDocument/authorization/consent. (OperativeNote)
treetree cda:templateId
1 .. 1 M SHALL contain exactly one [1..1] templateId (CONF:8483) such that it conf‑8483
treeblank treetree @root
1 .. 1 F 2.16.840.1.113883.10.20.22.1.7
treetree cda:code
1 .. 1 M SHALL contain exactly one [1..1] code (CONF:17187). conf‑17187
treetree cda:documentationOf
1 .. * M SHALL contain at least one [1..*] documentationOf (CONF:8486).

Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF).
conf‑8486
treeblank treetree cda:serviceEvent
1 .. 1 M Such documentationOfs SHALL contain exactly one [1..1] serviceEvent (CONF:8493).

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
conf‑8493
treeblank treeblank treetree cda:effectiveTime
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8494).

The serviceEvent/effectiveTime SHALL be present with effectiveTime/low.

If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high

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

The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
conf‑8494
  Schematron assert role red error
  test cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:low
  Message The serviceEvent/effectiveTime SHALL be present with effectiveTime/low.
  Schematron assert role red error
  test count(cda:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:high | cda:documentationOf/cda:serviceEvent/cda:effectiveTime/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:documentationOf/cda:serviceEvent/cda:effectiveTime/cda:high | cda:documentationOf/cda:serviceEvent/cda:effectiveTime/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
  Schematron assert role red error
  test string-length(cda:documentationOf/cda:serviceEvent/cda:effectiveTime//@value)>=8
  Message The content of effectiveTime SHALL be a conformant US Realm Date and Time (DT.US.FIELDED) (2.16.840.1.113883.10.20.22.5.4)
treeblank treeblank treetree cda:performer
1 .. 1 M This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8489) such that it conf‑8489
treeblank treeblank treeblank treetree @typeCode
1 .. 1 F PPRF
treeblank treeblank treeblank treetree cda:assignedEntity
1 .. 1 M SHALL contain exactly one [1..1] assignedEntity (CONF:10917). conf‑10917
treeblank treeblank treeblank treeblank treetree cda:code
1 .. 1 M This assignedEntity SHALL contain exactly one [1..1] code (CONF:8490). conf‑8490
  Schematron assert role red error
  test cda:documentationOf/cda:serviceEvent/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
treetree cda:component
1 .. 1 M SHALL contain exactly one [1..1] component (CONF:9585).

An Operative Note can have either a structuredBody or a nonXMLBody

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
Choice min 1 element(s) and max 1 element(s). Elements to choose from:
  • cda:nonXMLBody
  • cda:structuredBody
treeblank treeblank treetree cda:nonXMLBody
conf‑9585
treeblank treeblank treetree cda:structuredBody
conf‑9585
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.25']]
1 .. 1 M conf‑9883
  Contains 2.16.840.1.113883.10.20.22.2.25 Anesthesia Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.37']]
1 .. 1 M conf‑9885
  Contains 2.16.840.1.113883.10.20.22.2.37 Complications Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.34']]
1 .. 1 M conf‑9888
  Contains 2.16.840.1.113883.10.20.22.2.34 Preoperative Diagnosis Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.18.2.9']]
1 .. 1 M conf‑9890
  Contains 2.16.840.1.113883.10.20.18.2.9 Procedure Estimated Blood Loss Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.28']]
1 .. 1 M conf‑9892
  Contains 2.16.840.1.113883.10.20.22.2.28 Procedure Findings Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.31']]
1 .. 1 M conf‑9894
  Contains 2.16.840.1.113883.10.20.22.2.31 Procedure Specimens Taken Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.27']]
1 .. 1 M conf‑9896
  Contains 2.16.840.1.113883.10.20.22.2.27 Procedure Description Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.40']]
0 .. 1 conf‑9898
  Contains 2.16.840.1.113883.10.20.22.2.40 Procedure Implants Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.7.12']]
0 .. 1 conf‑9900
  Contains 2.16.840.1.113883.10.20.7.12 Operative Note Fluids Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.7.14']]
0 .. 1 conf‑9902
  Contains 2.16.840.1.113883.10.20.7.14 Operative Note Surgical Procedure Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.10']]
0 .. 1 conf‑9904
  Contains 2.16.840.1.113883.10.20.22.2.10 Plan of Care Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.30']]
0 .. 1 conf‑9906
  Contains 2.16.840.1.113883.10.20.22.2.30 Planned Procedure Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.18.2.12']]
0 .. 1 conf‑9908
  Contains 2.16.840.1.113883.10.20.18.2.12 Procedure Disposition Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.29']]
0 .. 1 conf‑9910
  Contains 2.16.840.1.113883.10.20.22.2.29 Procedure Indications Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.7.13']]
0 .. 1 conf‑9912
  Contains 2.16.840.1.113883.10.20.7.13 Surgical Drains Section (DYNAMIC)
treeblank treeblank treeblank treetree cda:component
where
[cda:section [cda:templateId/@root='2.16.840.1.113883.10.20.22.2.35']]
1 .. 1 M conf‑9913
  Contains 2.16.840.1.113883.10.20.22.2.35 Postoperative Diagnosis Section (DYNAMIC)