Gives information about the Procedures section
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The latest version of the PRSB documentation should be consulted for further information regarding Section headings and content http://theprsb.org
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 | Optional | 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 | O | 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.
- Procedures
See constructing clinical coded structures - Procedures