Surgery Procedures
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 the surgical procedure(s) performed during a surgery, recorded in structured data fields i.e. not in surgery reports. This is a nested data category, where surgery procedures are the child and surgeries are the parent. "
Overview
| Filter name in app | Priority | FHIR field (PFS) | Brief description | Example data |
|---|---|---|---|---|
| ID | Must have | Procedure.identifier.value | Unique identifier for surgery procedure. | |
| Surgery ID | Must have | Procedure.partOf | Unique ID of the full surgery that the surgery procedure is a part of. | |
| DBC ID | N/A | Not yet mapped | NL-specific: Unique ID of the DBC code (diagnosis-treatment-combination) that the surgery procedure is linked to. | |
| Episode of care ID | Could have | Not yet mapped | Unique identifier of the Episode of Care that the surgery procedure is linked to. I.e. indicates context in which the surgery procedure took place. | |
| Name | Must have | Procedure.code.coding.display | Name of the surgery procedure. | Heart cardioplegia, brain elektroshock, sentinal node removal. |
| Primary procedure | Should have | Not yet mapped | Indicates if the procedure is the primary procedure during the entire surgery, or a secondary activity. | Primary procedure, secondary procedure |
| Body site | Should have | Procedure.bodySite.coding.display | Body part on which the procedure is performed. | Arm, foot, head, breast, abdomen. |
| Laterality | Should have | Not yet mapped | Indicates on which side of the body the procedure is performed. | Both sides, left, right, not applicable |
| Surgeon | Should have | Prodcecude.performer.actor (Practitioner) | Main surgeon performing this particular procedure. | Dr. Borst |
| Assistant surgeon | Should have | Not yet mapped | Surgeon assisting in the execution of the procedure. | Dr. Smith |