HL7 Norway implementation guide for FHIR

Operation Note

The Operation Note is a document created by the responsible surgeon about a surgical operation which has been performed.

The description below describes how to generically exchange an Operation Note

Formal Definition

A formal definition of this profile can be found here.

XML Example of an Operation Note profile

An XML example that conforms to the profile.

RESTful Operations

HL7 Norway / DIPS needs to define which RESTful operations are supported for whom.

Create?

Read?

Update?

Delete?

Search parameters

HL7 Norway / DIPS needs to define on which attributes can be searched

Profile Description

Below is a visual representation of the nesting of the Operation Note profile, each arrow represents a reference to another resource.

structure

Operation Structure


This procedure represents the entire operation. It is derived from a Procedure resource, with the following constraints:

  • The subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The type of the procedure is of code: 10215-2 (surgical operation note findings) form codesystem: http://loinc.org
  • The indication of the procedure must be defined using a ICD-10 NO code.
  • The performers have to be a defined refer to a patient that is constraint as described in the #PerformerNorway structure. There has to be exactly one primary performer, and there can be 0 to infinite secondary performers.
  • The begin and end time of the operation must be specified

The procedure resource has also been constraint using the following extensions:

  • phase: this is a resourceReference to other procedure resources which describe the different phases of the operation
  • operatingRoom: is a resourceReference to the #LocationInformation structure which describes the information about the operating room.

PatientNorway Structure


This structure represents the a patient. It is derived from a Patient resource, with the following constraints:

  • A patient shall have at least 1, and at most 2 identifiers: Either the F-number or the D-number (in that order of preference; if both a F-number and a D-number are known, only the F-number shall be sent here), and the temporary identifier (H-number).
  • A patient must have a given and a family name,

PerformerNorway Structure


This structure represents the a performer. It is derived from a Performer resource, with the following constraints:

  • A performer shall be identified with a HPR-number.
  • A performer must have a given and a family name.

StayingPhase Structure


This procedure represents the entire staying phase of the operation. It is derived from a Procedure resource, with the following constraints:

  • The Subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The code of the procedure is fixed to "staying" from the value set: http://hl7.no/fhir/operation-phases
  • The begin date and time of this particular phase must be provided.

PreparationPhase Structure


This procedure represents the entire preparation phase of the operation. It is derived from a Procedure resource, with the following constraints:

  • The Subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The code of the procedure is fixed to "preparation" from the value set: http://hl7.no/fhir/operation-phases
  • The begin date and time of this particular phase must be provided.

AnesthesiaPhase Structure


This procedure represents the entire anesthesia phase of the operation. It is derived from a Procedure resource, with the following constraints:

  • The Subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The code of the procedure is fixed to "anesthesia from the value set: http://hl7.no/fhir/operation-phases
  • The begin date and time of this particular phase must be provided.

SurgeryPhase Structure


This procedure represents the entire surgery phase of the operation. It is derived from a Procedure resource, with the following constraints:

  • The Subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The code of the procedure is fixed to "Surgery" from the value set: http://hl7.no/fhir/operation-phases
  • The begin date and time of this particular phase must be provided.

Extensions:

  • performedProcedure: A ResourceReference to 0 to infinite #performedProcedure structures, which describe the procedures that were performed during to operation.

TransportPhase Structure


This procedure represents the entire transport phase of the operation. It is derived from a Procedure resource, with the following constraints:

  • The Subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The code of the procedure is fixed to "transport" from the value set: http://hl7.no/fhir/operation-phases
  • The begin date and time of this particular phase must be provided.

Extensions:

  • transport: A resourceReference to the #LocationInformation structure which describes the information about the operating room.

LocationInformation Structure


This structure represents a location. It is derived from a Location resource, with the following constraints:

  • Must have an identifier from the code system: urn:oid:2.16.578.1.34.1000.4
  • A name of the location may also be provided

PerformedProcedure Structure


This procedure represents the entire anestesi phase of the operation. It is derived from a Procedure resource, with the following constraints:

  • The Subject has to be a defined refer to a patient that is constraint as described in the #PatientNorway structure.
  • The code of the procedure has to be from either NCSP Norwegian (surgical procedure) (urn:oid:2.16.578.1.12.4.1.1.7210) or NCMP Norwegian (medical procedure) (urn:oid:2.16.578.1.12.4.1.1.7220)

Extension:

  • sequenceNumber: Used to distinguish the relative importance of the procedures; if number equals 1, the procedure is considered to be the main (Norwegian: Hoved) procedure. If the value is larger than 1 it is a supporting procedure.

Use Case

Mr.Testesen arrived in the hospital with acute pain in the stomach. Appendicitis is diagnosed and an immediate operation is requested. Dr. Aril Horn is the surgeon on duty. He performs a laparoscopic appendectomy. After the operation he records the performed surgery in the operation system. These codes together with some other information are sent to the EHR system. An example can be found below:


PasientID: 120659-45897

Pasient Navne: Testesen, Test

Operajsjon: Gastro Appendectomi

Hovedoperatør: Horn Arild

Operatør: Øvrebø Kjell

Operasjonsstue: SOP04

Operation Phase Date Time Note
Patient Mottatt 16.12.2008 06.54
Anestesi start 16.12.2008 07.06
Klar for operasjon 16.12.2008 07.21
Knivtid-start 16.12.2008 07.22
Knivtid-slutt 16.12.2008 07.34 varighet 12 min
Pasient fra operasjonsstue 16.12.2008 07.54
Pasient levert/Anestesi slutt 16.12.2008 08.01 til Postoperativ seksjon

Prosedyrer utført ved operasjon

JEA00 Lapraskopisk appendektomi (hoved)

indikasjonsdiagnose

K359 Uspesifisert akutt appendisitt


A formal definition of this profile can be found here.