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
This text section should be linked to the following FHIR Resources to provide the textual information in a coded format.
See constructing clinical coded structures - Procedures