description: The Operative Note is a frequently used type of procedure note with specific requirements set forth by regulatory agencies. \n\nThe Operative Note is created immediately following a surgical or other high-risk procedure. It records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. The report should be sufficiently detailed to support the diagnoses, justify the treatment, document the course of the procedure, and provide continuity of care.\n\n#### Document Sections\nAlthough document templates may contain any section, the following sections are specifically called out by this template:\n\n**Required Sections**\n- [AnesthesiaSection](StructureDefinition-AnesthesiaSection.html)\n- [ComplicationsSection](StructureDefinition-ComplicationsSection.html)\n- [PreoperativeDiagnosisSection](StructureDefinition-PreoperativeDiagnosisSection.html)\n- [ProcedureEstimatedBloodLossSection](StructureDefinition-ProcedureEstimatedBloodLossSection.html)\n- [ProcedureFindingsSection](StructureDefinition-ProcedureFindingsSection.html)\n- [ProcedureSpecimensTakenSection](StructureDefinition-ProcedureSpecimensTakenSection.html)\n- [ProcedureDescriptionSection](StructureDefinition-ProcedureDescriptionSection.html)\n- [PostoperativeDiagnosisSection](StructureDefinition-PostoperativeDiagnosisSection.html)\n\n**Additional Sections**\n- [ProcedureImplantsSection](StructureDefinition-ProcedureImplantsSection.html)\n- [OperativeNoteFluidsSection](StructureDefinition-OperativeNoteFluidsSection.html)\n- [OperativeNoteSurgicalProcedureSection](StructureDefinition-OperativeNoteSurgicalProcedureSection.html)\n- [PlanofTreatmentSection](StructureDefinition-PlanofTreatmentSection.html)\n- [PlannedProcedureSection](StructureDefinition-PlannedProcedureSection.html)\n- [ProcedureDispositionSection](StructureDefinition-ProcedureDispositionSection.html)\n- [ProcedureIndicationsSection](StructureDefinition-ProcedureIndicationsSection.html)\n- [SurgicalDrainsSection](StructureDefinition-SurgicalDrainsSection.html)\n- [AdvanceDirectivesSection](StructureDefinition-AdvanceDirectivesSection.html) package_name: rs/hl7.cda.us.ccda derivation: constraint name: OperativeNote type: http://hl7.org/cda/stds/core/StructureDefinition/ClinicalDocument elements: templateId: array: true min: 2 index: 0 slicing: slices: operative-note: match: {} schema: _required: true index: 1 elements: root: pattern: {type: string, value: 2.16.840.1.113883.10.20.22.1.7} type: string index: 2 extension: pattern: {type: string, value: '2024-05-01'} type: string index: 3 required: [extension, root] extensions: {} sdtcCategory: {short: 'Used to categorize the document as a Operative Note. If present, there SHALL be a category of 11504-8 (Surgical operation note).', index: 4} code: short: The Operative Note recommends use of a single document type code, 11504-8 "Surgical operation note", with further specification provided by author or performer, setting, or specialty data in the CDA header. Some of the LOINC codes in the Surgical Operation Note Document Type Code table are pre-coordinated with the practice setting or the training or professional level of the author. Use of pre-coordinated codes is not recommended because of potential conflict with other information in the header. When these codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type. binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.11.20.1.1'} index: 5 documentationOf: short: A serviceEvent represents the main act, such as a colonoscopy or an appendectomy, being documented. A serviceEvent can further specialize the act inherent in the ClinicalDocument/code, such as where the ClinicalDocument/code is simply "Surgical Operation Note" and the procedure is "Appendectomy." serviceEvent is required in the Operative Note and it must be equivalent to or further specialize the value inherent in the ClinicalDocument/code; it shall not conflict with the value inherent in the ClinicalDocument/code, as such a conflict would create ambiguity. serviceEvent/effectiveTime can be used to indicate the time the actual event (as opposed to the encounter surrounding the event) took place. If the date and the duration of the procedure is known, serviceEvent/effectiveTime/low is used with a width element that describes the duration; no high element is used. However, if only the date is known, the date is placed in both the low and high elements. index: 6 elements: serviceEvent: index: 7 elements: code: constraint: 1198-8487: {human: 'The value of Clinical Document /documentationOf/serviceEvent/code SHALL be from ICD-9-CM Procedures (codeSystem 2.16.840.1.113883.6.104), ICD-10-PCS (codeSystem 2.16.840.1.113883.6.4), CPT (codeSystem 2.16.840.1.113883.6.12), or values descending from 71388002 (Procedure) from the SNOMED CT (codeSystem 2.16.840.1.113883.6.96) ValueSet 2.16.840.1.113883.3.88.12.80.28 Procedure DYNAMIC (CONF:1198-8487).', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote', severity: error, expression: 'codeSystem = ''2.16.840.1.113883.6.104'' or codeSystem = ''2.16.840.1.113883.6.4'' or codeSystem = ''2.16.840.1.113883.6.12'' or (codeSystem = ''2.16.840.1.113883.6.96'' and code.memberOf(''http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.88.12.80.28''))'} index: 8 effectiveTime: constraint: width-or-high: {human: 'Width and high are mutually exclusive. If width is known, high **SHALL NOT** be present. If with is not present, **SHALL** include high.', source: 'http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote', severity: error, expression: (width | high).count() = 1} index: 9 elements: low: {short: Low is required, index: 10} width: {short: Represents the duration, index: 11} high: {short: Equals low if only the date is known, index: 12} performer: index: 13 slicing: rules: open discriminator: - {path: typeCode, type: value} min: 1 slices: primary: match: {typeCode: PPRF} schema: short: This performer represents clinicians who actually and principally carry out the serviceEvent. Typically, these are clinicians who have surgical privileges in their institutions such as Surgeons, Obstetrician/Gynecologists, and Family Practice Physicians. The performer may also be non-physician providers (NPPs) who have surgical privileges. There may be more than one primary performer in the case of complicated surgeries. There are occasionally co-surgeons. Usually they will be billing separately and will each dictate their own notes. An example may be spinal surgery , where a general surgeon and an orthopedic surgeon both are present and billing off the same Current Procedural Terminology (CPT) codes. Typically two Operative Notes are generated; however, each will list the other as a co-surgeon. Any assistants are identified as a secondary performer (SPRF) in a second performer participant. array: true min: 1 _required: true index: 14 elements: typeCode: pattern: {type: code, value: PPRF} type: code index: 15 functionCode: binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30'} index: 16 assignedEntity: constraint: should-code: {human: SHOULD contain code, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote', severity: warning, expression: code.exists()} index: 17 elements: code: binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066'} index: 18 secondary: match: {typeCode: SPRF} schema: short: This performer represents any assistants array: true index: 19 elements: typeCode: pattern: {type: code, value: SPRF} type: code index: 20 functionCode: binding: {strength: preferred, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.30'} index: 21 assignedEntity: constraint: should-code: {human: SHOULD contain code, source: 'http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote', severity: warning, expression: code.exists()} index: 22 elements: code: binding: {strength: required, valueSet: 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.1066'} index: 23 required: [code, performer] authorization: short: Authorization represents consent. Consent, if present, shall be represented by authorization/consent. index: 24 elements: typeCode: {index: 25} consent: index: 26 elements: classCode: {index: 27} moodCode: {index: 28} statusCode: {index: 29} required: [classCode, moodCode] required: [typeCode] component: index: 30 elements: structuredBody: index: 31 elements: component: array: true min: 8 index: 32 slicing: rules: open discriminator: - {path: section, type: profile} min: 8 slices: findings: match: {} schema: _required: true index: 41 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 42} estBloodLoss: match: {} schema: _required: true index: 39 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 40} surgicalProcedures: match: {} schema: index: 53 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 54} complications: match: {} schema: _required: true index: 35 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 36} specimensTaken: match: {} schema: _required: true index: 43 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 44} procedureDescription: match: {} schema: _required: true index: 45 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 46} fluids: match: {} schema: index: 51 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 52} postopDx: match: {} schema: _required: true index: 47 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 48} plannedProcedure: match: {} schema: index: 57 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 58} disposition: match: {} schema: index: 59 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 60} implants: match: {} schema: index: 49 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 50} planOfTreatment: match: {} schema: index: 55 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 56} indications: match: {} schema: index: 61 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 62} anesthesia: match: {} schema: _required: true index: 33 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 34} advDirectives: match: {} schema: index: 65 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 66} surgicalDrains: match: {} schema: index: 63 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 64} preopDx: match: {} schema: _required: true index: 37 elements: section: {type: 'http://hl7.org/cda/stds/core/StructureDefinition/Section', index: 38} required: [structuredBody] package_version: 4.0.0-ballot class: logical kind: logical url: http://hl7.org/cda/us/ccda/StructureDefinition/OperativeNote base: http://hl7.org/cda/us/ccda/StructureDefinition/USRealmHeader version: 4.0.0-ballot required: [documentationOf]