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Procedures
The Procedures section carries information about the procedures that have been performed on the patient. PRSB Elements should be formatted as subheadings in any HTML sent.
Section | Description | Card. | MRO* | FHIR Target and Guidance |
---|---|---|---|---|
Procedures | The details of any procedures performed. | 0 to 1 | Optional | Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode |
PRSB Element | Description | Card. | MRO* | FHIR Target and Guidance |
Procedure name | The therapeutic or diagnostic procedure performed. | 1 only | O | The procedure name in text and where supported a SNOMED CT concept from 71388002 Procedure (procedure) hierarchy or Procedure with explicit context (situation)129125009. Carried in the FHIR element Procedure.code See Procedure List (Procedure name) |
Anatomical site | The body site of the procedure | 0 to 1 | O | Text and where supported a SNOMED CT concept to represent the anatomical site carried in Procedure.bodySite. |
Laterality | Laterality of the procedure | 0 to 1 | O | Text and where supported a SNOMED CT concept to represent the laterality carried in Procedure.bodySite (if part of the pre-coordinated term). |
Complications related to procedure | Details of any intra-operative complications encountered during the procedure, arising during the patient's stay in the recovery unit or directly attributable to the procedure. | 0 to many | O | Text and where supported a SNOMED CT concept to represent the complication carried in the FHIR element Procedure.complication. |
Specific anaesthesia issues | Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc. | 0 to many | O | Text and where supported either a SNOMED CT concept or a reference to the Condition Resource to represent the anaesthesia issues carried using the extension Extension-CareConnect-AnaestheticIssues-1. |
Comment | Any further textual comment to clarify such as statement that information is partial or incomplete. | 0 to 1 | O | Free text |
* M=Mandatory R=Required O=Optional |
Example Procedures Section
{ "resourceType": "Composition", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" ] }, "status": "final", "type": { "coding": [ { "system": "http://snomed.info/sct", "code": "373942005", "display": "Discharge summary" } ] }, "subject": { "reference": "urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" }, "encounter": { "reference": "urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" }, "date": "2015-02-17T10:00:00+00:00", "author": [ { "reference": "urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc" } ], "title": "Cardiology Service Discharge Summary", "section": [ { "title": "Procedures", "code": { "coding": [ { "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings", "code": "procedures", "display": "Procedures" } ] }, "text": { "status": "additional", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Procedure name</th><td>Percutaneous coronary intervention</td></tr><tr><th>Anatomical site</th><td>Right coronary artery structure</td></tr><tr><th>Comment</th><td>Patient successfully underwent angioplasty procedure to place a drug eluting stent.</td></tr></tbody></table></div>" }, "entry": [ { "reference": "urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" } ] } ] }
<Composition xmlns="http://hl7.org/fhir"> <!-- optional elements removed for readability --> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" /> </meta> <status value="final" /> <type> <coding> <system value="http://snomed.info/sct" /> <code value="373942005" /> <display value="Discharge summary" /> </coding> </type> <subject> <reference value="urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" /> </subject> <encounter> <reference value="urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" /> </encounter> <date value="2015-02-17T10:00:00+00:00" /> <author> <reference value="urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc" /> </author> <title value="Cardiology Service Discharge Summary" /> <section> <title value="Procedures" /> <code> <coding> <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" /> <code value="procedures" /> <display value="Procedures" /> </coding> </code> <text> <status value="additional" /> <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Procedure name</th><td>Percutaneous coronary intervention</td></tr><tr><th>Anatomical site</th><td>Right coronary artery structure</td></tr><tr><th>Comment</th><td>Patient successfully underwent angioplasty procedure to place a drug eluting stent.</td></tr></tbody></table></div> </text> <entry> <reference value="urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" /> </entry> </section> </Composition>
Example Coded Resources
This text section should be linked to a UKCore-List profiled resource. E.g.
{ "resourceType": "List", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-List" ] }, "identifier": [ { "system": "https://tools.ietf.org/html/rfc4122", "value": "cdd92a18-ffb2-4e3f-aacf-de0e01bb3120" } ], "status": "current", "mode": "snapshot", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "887171000000109", "display": "Procedures" } ] }, "subject": { "reference": "urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" }, "encounter": { "reference": "urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" }, "source": { "reference": "urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc" }, "entry": [ { "item": { "reference": "urn:uuid:6ea2da97-73e2-4507-b7a5-f7c0325021a9" } } ] }
<List xmlns="http://hl7.org/fhir"> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-List" /> </meta> <identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="cdd92a18-ffb2-4e3f-aacf-de0e01bb3120" /> </identifier> <status value="current" /> <mode value="snapshot" /> <code> <coding> <system value="http://snomed.info/sct" /> <code value="887171000000109" /> <display value="Procedures" /> </coding> </code> <subject> <reference value="urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" /> </subject> <encounter> <reference value="urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" /> </encounter> <source> <reference value="urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc" /> </source> <entry> <item> <reference value="urn:uuid:6ea2da97-73e2-4507-b7a5-f7c0325021a9" /> </item> </entry> </List>
This list linked to a UKCore-Procedure profiled resource. E.g.
{ "resourceType": "Procedure", "meta": { "profile": [ "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Procedure" ] }, "identifier": [ { "system": "https://tools.ietf.org/html/rfc4122", "value": "1f2f7b4e-8a61-4211-95b6-034a9a85df58" } ], "status": "completed", "code": { "coding": [ { "system": "http://snomed.info/sct", "code": "415070008", "display": "Percutaneous coronary intervention" } ] }, "subject": { "reference": "urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" }, "encounter": { "reference": "urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" }, "bodySite": [ { "coding": [ { "system": "http://snomed.info/sct", "code": "13647002", "display": "Right coronary artery structure" } ] } ] }
<Procedure xmlns="http://hl7.org/fhir"> <meta> <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Procedure" /> </meta> <identifier> <system value="https://tools.ietf.org/html/rfc4122" /> <value value="1f2f7b4e-8a61-4211-95b6-034a9a85df58" /> </identifier> <status value="completed" /> <code> <coding> <system value="http://snomed.info/sct" /> <code value="415070008" /> <display value="Percutaneous coronary intervention" /> </coding> </code> <subject> <reference value="urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" /> </subject> <encounter> <reference value="urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" /> </encounter> <bodySite> <coding> <system value="http://snomed.info/sct" /> <code value="13647002" /> <display value="Right coronary artery structure" /> </coding> </bodySite> </Procedure>