Non-Normative Content The Normative content for these specifications may be found on the HL7, IHE, and HITSP web sites.

Operative Note

[ClinicalDocument: templateId 2.16.840.1.113883.10.20.22.1.7]

The Operative Note Fluids section may be used to record fluids administered during the surgical procedure.

Operative Note Header Constraints

Operative Note Body Constraints

  1. SHALL contain exactly one [1..1] templateId ( CONF:8483, CONF:10048 ) such that it
    1. SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.22.1.7"
  2. SHALL conform to General Header Constraints template (templateId: 2.16.840.1.113883.10.20.22.1.1) (CONF:9914, CONF:10047)
  3. SHALL contain exactly one [1..1] code (CONF:17187), where the @code SHALL be selected from ValueSet SurgicalOperationNoteDocumentTypeCode 2.16.840.1.113883.11.20.1.1 DYNAMIC (CONF:17188)
  4. SHALL contain at least one [1..*] documentationOf (CONF:8486)
    1. Such documentationOfs SHALL contain exactly one [1..1] serviceEvent (CONF:8493)
      1. This serviceEvent SHALL contain exactly one [1..1] performer (CONF:8489)

        The performer represents clinicians who actually and principally carry out the serviceEvent.  Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians.  The performer may also be Nonphysician Providers (NPP) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries.  There are occasionally co-surgeons.  Usually they will be billing separately and will each dictate their own notes.  An example may be spinal surgery , where a general surgeon and an orthopaedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes.  Typically two Operative Notes are generated; however, each will list the other as a co-surgeon.

        1. This performer SHALL contain exactly one [1..1] @typeCode="PPRF" (CONF:8495)
        2. This performer SHALL contain exactly one [1..1] assignedEntity (CONF:10917)
          1. This assignedEntity SHALL contain exactly one [1..1] code (CONF:8490, CONF:8491), where the @code SHALL be selected from ValueSet ProviderType 2.16.840.1.113883.3.88.12.3221.4 DYNAMIC

        The performer represents clinicians who actually and principally carry out the serviceEvent.  Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians.  The performer may also be Nonphysician Providers (NPP) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries.  There are occasionally co-surgeons.  Usually they will be billing separately and will each dictate their own notes.  An example may be spinal surgery , where a general surgeon and an orthopaedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes.  Typically two Operative Notes are generated; however, each will list the other as a co-surgeon.

      2. This serviceEvent SHALL contain exactly one [1..1] code (i., CONF:8487)
      3. This serviceEvent SHALL contain exactly one [1..1] effectiveTime (CONF:8494)
      4. This serviceEvent 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:8487)
      5. This serviceEvent The serviceEvent/effectiveTime SHALL be present with effectiveTime/low (CONF:8488)
      6. This serviceEvent If a width is not present, the serviceEvent/effectiveTime SHALL include effectiveTime/high. (CONF:10058)
      7. This serviceEvent 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. (CONF:10060)
      8. This serviceEvent Any assistants SHALL be identified and SHALL be identified as secondary performers (SPRF)
  5. SHALL contain exactly one [1..1] component (CONF:9883)
    1. Contains exactly one [1..1] Anesthesia Section (templateId: 2.16.840.1.113883.10.20.22.2.25)
  6. SHALL contain exactly one [1..1] component (CONF:9885)
    1. Contains exactly one [1..1] Complications Section (templateId: 2.16.840.1.113883.10.20.22.2.37)
  7. SHALL contain exactly one [1..1] component (CONF:9913)
    1. Contains exactly one [1..1] Postoperative Diagnosis Section (templateId: 2.16.840.1.113883.10.20.22.2.35)
  8. SHALL contain exactly one [1..1] component (CONF:9888)
    1. Contains exactly one [1..1] Preoperative Diagnosis Section (templateId: 2.16.840.1.113883.10.20.22.2.34)
  9. SHALL contain exactly one [1..1] component (CONF:9890)
    1. Contains exactly one [1..1] Procedure Estimated Blood Loss Section (templateId: 2.16.840.1.113883.10.20.18.2.9)
  10. SHALL contain exactly one [1..1] component (CONF:9892)
    1. Contains exactly one [1..1] Procedure Findings Section (templateId: 2.16.840.1.113883.10.20.22.2.28)
  11. SHALL contain exactly one [1..1] component (CONF:9894)
    1. Contains exactly one [1..1] Procedure Specimens Taken Section (templateId: 2.16.840.1.113883.10.20.22.2.31)
  12. SHALL contain exactly one [1..1] component (CONF:9896)
    1. Contains exactly one [1..1] Procedure Description Section (templateId: 2.16.840.1.113883.10.20.22.2.27)
  13. MAY contain zero or one [0..1] component (CONF:9898)
    1. Contains exactly one [1..1] Procedure Implants Section (templateId: 2.16.840.1.113883.10.20.22.2.40)
  14. MAY contain zero or one [0..1] component (CONF:9900)
    1. Contains exactly one [1..1] Operative Note Fluid Section (templateId: 2.16.840.1.113883.10.20.7.12)
  15. MAY contain zero or one [0..1] component (CONF:9902)
    1. Contains exactly one [1..1] Operative Note Surgical Procedure Section (templateId: 2.16.840.1.113883.10.20.7.14)
  16. MAY contain zero or one [0..1] component (CONF:9904)
    1. Contains exactly one [1..1] Plan Of Care Section (templateId: 2.16.840.1.113883.10.20.22.2.10)
  17. MAY contain zero or one [0..1] component (CONF:9906)
    1. Contains exactly one [1..1] Planned Procedure Section (templateId: 2.16.840.1.113883.10.20.22.2.30)
  18. MAY contain zero or one [0..1] component (CONF:9908)
    1. Contains exactly one [1..1] Procedure Disposition Section (templateId: 2.16.840.1.113883.10.20.18.2.12)
  19. MAY contain zero or one [0..1] component (CONF:9910)
    1. Contains exactly one [1..1] Procedure Indications Section (templateId: 2.16.840.1.113883.10.20.22.2.29)
  20. MAY contain zero or one [0..1] component (CONF:9912)
    1. Contains exactly one [1..1] Surgical Drains Section (templateId: 2.16.840.1.113883.10.20.7.13)

Operative Note Example

<?xml version="1.0" encoding="UTF-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns="urn:hl7-org:v3" xsi:schemaLocation="urn:hl7-org:v3 CDA.xsd">
  <typeId root="2.16.840.1.113883.1.3"/>
  <id root="MDHT" extension="2039487761"/>
  <code code="218427040"/>
  <title>TEXT FOR TITLE</title>
  <effectiveTime/>
  <confidentialityCode code="1654694806"/>
  <setId root="MDHT" extension="054fb651-2ab9-43fa-ba8a-f516fcea0c27"/>
  <versionNumber value="1"/>
  <recordTarget>
    <typeId root="2.16.840.1.113883.1.3"/>
    <patientRole/>
  </recordTarget>
  <author>
    <typeId root="2.16.840.1.113883.1.3"/>
    <time/>
    <assignedAuthor/>
  </author>
  <custodian/>
  <documentationOf>
    <serviceEvent>
      <code code="1771019455"/>
      <effectiveTime>
        <low value="2013"/>
        <high value="2013"/>
      </effectiveTime>
      <performer typeCode="PPRF"/>
    </serviceEvent>
  </documentationOf>
  <component>
    <structuredBody>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="574861437"/>
          <code code="1467658955"/>
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          <confidentialityCode code="739968957"/>
          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="836508182"/>
              <code code="1263850359"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <specimen/>
              <performer/>
              <entryRelationship typeCode="COMP" inversionInd="true"/>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <substanceAdministration classCode="SBADM"/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
            </procedure>
          </entry>
          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="2105790990"/>
              <code code="2128961070"/>
              <effectiveTime value="20130627"/>
              <consumable/>
              <performer/>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <act/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <supply classCode="SPLY"/>
              </entryRelationship>
              <precondition/>
            </substanceAdministration>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
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          <confidentialityCode code="1312290176"/>
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              <id root="MDHT" extension="1550084836"/>
              <code code="1405678025"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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              <entryRelationship>
                <observation/>
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              <id root="MDHT" extension="897830349"/>
              <code code="1811649884"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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              <entryRelationship>
                <observation/>
              </entryRelationship>
            </act>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
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      <component>
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          <entry>
            <observation>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1878992763"/>
              <code code="2110145450"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
              </effectiveTime>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
              <entryRelationship>
                <observation/>
              </entryRelationship>
            </observation>
          </entry>
        </section>
      </component>
      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="622240102"/>
          <code code="1065168568"/>
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      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
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              <code code="197655244"/>
              <effectiveTime>
                <low value="2013"/>
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          <entry>
            <encounter>
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              <id root="MDHT" extension="1699227492"/>
              <code code="1980372407"/>
              <effectiveTime>
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              <id root="MDHT" extension="2004207245"/>
              <code code="316858127"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1617543065"/>
              <code code="1987161381"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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            </procedure>
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          <entry>
            <substanceAdministration classCode="SBADM">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1897297446"/>
              <code code="89505602"/>
              <effectiveTime value="20130627"/>
              <consumable/>
            </substanceAdministration>
          </entry>
          <entry>
            <supply classCode="SPLY">
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1979235282"/>
              <code code="143914593"/>
              <effectiveTime value="20130627"/>
            </supply>
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          <entry>
            <act>
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              <id root="MDHT" extension="1227199110"/>
              <code code="1978084853"/>
              <effectiveTime>
                <low value="2013"/>
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          <entry>
            <procedure>
              <typeId root="2.16.840.1.113883.1.3"/>
              <id root="MDHT" extension="1970287535"/>
              <code code="1194153518"/>
              <effectiveTime>
                <low value="2013"/>
                <high value="2013"/>
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      <component>
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          <code code="175887151"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="208210186"/>
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      <component>
        <section>
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          <entry>
            <observation>
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              <id root="MDHT" extension="187941282"/>
              <code code="1795542594"/>
              <effectiveTime>
                <low value="2013"/>
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      <component>
        <section>
          <typeId root="2.16.840.1.113883.1.3"/>
          <id root="MDHT" extension="853386811"/>
          <code code="1982550802"/>
          <title>TEXT FOR TITLE</title>
          <confidentialityCode code="1429173706"/>
        </section>
      </component>
    </structuredBody>
  </component>
</ClinicalDocument>