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Procedures Section

Gives information about the Procedures section

Procedures Section Content

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 required Carried in the CodeableConcept of Composition.section.code FHIR element.
PRSB Element Description Card. MRO* FHIR Target and Guidance
Procedure name The therapeutic or diagnostic procedure performed. 1 only M 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 Constructing Procedure Lists (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 Sections

Coded Resources

This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.

  • Procedure

See constructing clinical coded structures - Procedures

Tags: fhir

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