Surgeries
In FHIR, these are known as 'Procedures' and are combined with care activities. If the EHR source clearly indicates that a procedure is a surgery, or allows for distinction of surgeries from other procedures based on information in the EHR, we map surgery information to this separate category. Otherwise, it is made available.
This category contains information on a surgery that is recorded in a structured way; so not information recorded in free text in, for example, surgery reports. At least one surgery procedure (nested category linked to the surgery term) is performed during a surgery.
Overview
| Filter name in app | Priority | FHIR field (PFS) | Brief description | Example data |
|---|---|---|---|---|
| ID | Must have | Procedure.identifier.value | Unique identifier for surgery. | |
| DBC ID | N/A | Not yet mapped | NL-specific: Unique ID of the DBC code (diagnosis-treatment-combination) that the surgery is linked to. | |
| Episode of care ID | Could have | Not yet mapped | Unique identifier of the Episode of Care that the surgery is linked to. I.e. indicates context in which the surgery took place. | |
| Indication | Must have | Procedure.code.coding.display | Description of the surgery. | Cornea transplantation, cataract, primary sectio, mastectomy. |
| Expected duration | Could have | Not yet mapped | Expected duration of the surgery, in minutes. | 120 min. |
| Duration | Should have | Not yet mapped | Actual duration of the surgery, in minutes | 116 min. |
| Head surgeon | Should have | Procedure.performer (Practitioner) | Head surgeon, main responsible surgeon, for the entire surgery. | Dr. Smith. |
| Body position | Could have | Procedure.bodySite.coding.display | Positioning of the patient's body during the surgery. | Back, prone position, left lateral position. |
| Anaesthesia types | Should have | Not yet mapped | Type of anaesthesia used during the surgery. | General anaesthesia, epidural, peridural. |
| Operating room department | Could have | Procedure.location | Department where the OR is located. | |
| Operating room location | Could have | Procedure.location | The location (hospital building) of the operating room. | Location east, location south. |
| Operating room | Could have | Procedure.location | Name or number of the operating theater. | OR1, OR blue. |
| Age at time of event | Must have | Derived from Patient (Procedure.subject) | Age of the patient, in years, when the surgery started. | |
| Status | Must have | Procedure.status | Status of the surgery. | Planned, waiting list, post-operative. |
| Specialism | Should have | Procedure.performer.onBehalfOf | Specialism performing the surgery. | Surgery, orthopaedics, gynaecology. |
| Location | Should have | Procedure.location | The location (hospital building) where the surgery is taking place. | Location east, location south. |
| Priority | Could have | Not yet mapped | Textual value indicating the urgency of the surgery compared to other surgeries. | Emergency, regular, within 24 hours. |
| Type | Could have | Not yet mapped | Type of surgery. Usually associated with admission time of a patient (brief at the daycare unit or longer at a clinical ward). | Clinical, daycare. |
| ASA score | Should have | Not yet mapped | International classification system that indicates fitness or overall condition of the patient. | 1, 2, 3, 4, 5, 6. |
| Start date | Must have | Procedure.performed[x] | Date on which the surgery started. | DD-MM-YYYY hh:mm |
| Request date | Should have | Not yet mapped | Date on which the surgery was requested. | DD-MM-YYYY hh:mm |
| Patient ordered | Could have | Not yet mapped | Moment on which the patient was ordered to move to the surgical ward. | DD-MM-YYYY hh:mm |
| Arrival surgical ward | Could have | Not yet mapped | Moment the patient arrives at the surgical ward. | DD-MM-YYYY hh:mm |
| Pre-medication | Could have | Not yet mapped | Moment the pre-surgery-medication is administered. | DD-MM-YYYY hh:mm |
| In holding date | Could have | Not yet mapped | Moment the patient arrives at the holding room. | DD-MM-YYYY hh:mm |
| Arrival operating room | Could have | Not yet mapped | Moment the patient arrives in the surgery theater. | DD-MM-YYYY hh:mm |
| Induction anaesthesia (start) | Could have | Not yet mapped | Moment the induction of aenasthesia is started. | DD-MM-YYYY hh:mm |
| Induction anaesthesia (end) | Could have | Not yet mapped | Moment the induction of aenasthesia is completed. | DD-MM-YYYY hh:mm |
| Local anaesthesia (start) | Could have | Not yet mapped | Moment induction of locoregional anaesthesia is started. | DD-MM-YYYY hh:mm |
| Local anaesthesia (end) | Could have | Not yet mapped | Moment induction of locoregional anaesthesia is completed. | DD-MM-YYYY hh:mm |
| Surgical time (start) | Should have | Not yet mapped | Moment the surgeons start their work i.e. moment the first incision is made. | DD-MM-YYYY hh:mm |
| Surgical time (end) | Should have | Not yet mapped | Moment the surgeons finish their work i.e. moment the cutting ends. | DD-MM-YYYY hh:mm |
| Departure operating room | Could have | Not yet mapped | Moment the patient leaves the operating theatre. | DD-MM-YYYY hh:mm |
| Arrival recovery | Could have | Not yet mapped | Moment the patient arrives in the recovery facility. | DD-MM-YYYY hh:mm |
| Departure recovery | Could have | Not yet mapped | Moment the patient leaves the recovery facility. | DD-MM-YYYY hh:mm |
| Departire surgical ward | Could have | Not yet mapped | Moment the patient leaves the surgical ward. Either to go home, for monitoring in the daycare unit or to be admitted at one of the wards in hospital (eg. ICU, MCU. Cardiology etc.) | DD-MM-YYYY hh:mm |
| Planned start date | Should have | Not yet mapped | Planned start date and time for the surgery. This may differ from the actual start date of the surgery if the surgery starts earlier or is delayed / postponed. |
DD-MM-YYYY hh:mm |