Procedure Indications Section - Sample Code
displayName="PROCEDURE INDICATIONS"/>
titleProcedure Indications</title
text ID="indication1">The procedure is performed for screening in a low risk individual. </text
entry
observation classCode="OBS" moodCode="EVN">
templateId root="2.16.840.1.113883.10.20.22.4.19" extension="2014-06-09"/>
id root="db734647-fc99-424c-a864-7e3cda82e703" extension="45665"/>
code code="75321-0" displayName="Clinical finding" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/>
text
reference value="#indication1"/>
</text
statusCode code="completed"/>
effectiveTime
low value="20091023"/>
</effectiveTime
value xsi:type="CD" code="414992000" displayName="Painless rectal bleeding" codeSystem="2.16.840.1.113883.6.96"/>
</observation
</entry
</section
</component
<!-- *** PLANNED PROCEDURE *** -->
component
section
templateId root="2.16.840.1.113883.10.20.22.2.30" extension="2014-06-09"/>
<!-- *** Planned Procedure Section *** -->
code code="59772-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"
Procedure Description Section Sample code
- *** PROCEDURE DESCRIPTION *** -->
component
section
templateId root="2.16.840.1.113883.10.20.22.2.27"/>
code code="29554-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="PROCEDURE DESCRIPTION"/>
titlePROCEDURE DESCRIPTION</title
textThe patient was brought to the operating room, placed in the supine position, and general anesthesia was induced. A detailed technical
narrative of a laparoscopic appendectomy from initial incision to placement of any dressings follows.</text
</section
Complications Section – Sample Code
<!-- *** COMPLICATIONS *** -->
component
section
templateId root="2.16.840.1.113883.10.20.22.2.37" extension="2014-06-09"/>
code code="55109-3" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Complications"/>
titleComplications</title
text ID="complic1">Asthmatic symptoms while under general anesthesia. </text
entry
observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
id root="cd1791b0-5c71-11db-b0de-0800200c9a66"/>
code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
text
reference value="#complic1"/>
</text
statusCode code="completed"/>
effectiveTime
low value="20080103"/>
</effectiveTime
value xsi:type="CD" code="390798007" codeSystem="2.16.840.1.113883.6.96" displayName="asthma finding"/>
author
templateId root="2.16.840.1.113883.10.20.22.4.119"/>
time value="20050329224411+0500"/>
assignedAuthor
id extension="99999999" root="2.16.840.1.113883.4.6"/>
</assignedAuthor
</author
</observation
</entry
</section
Post Procedure Diagnosis Section Sample code
<!-- *** POSTOPERATIVE DIAGNOSIS *** -->
component
section
templateId root="2.16.840.1.113883.10.20.22.2.35"/>
code code="10218-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="POSTOPERATIVE DIAGNOSIS"/>
titlePostoperative Diagnosis</title
textAppendicitis with periappendiceal abscess</text
</section
</component
<!-- *** POSTPROCEDURE DIAGNOSIS *** -->
component
section
templateId root="2.16.840.1.113883.10.20.22.2.36" extension="2014-06-09"/>
code code="59769-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="POSTPROCEDURE DIAGNOSIS"/>
titlePostprocedure Diagnosis</title
text
list listType="ordered">
item ID="ppdx1">Sigmoid diverticulosis, moderate</item
item ID="ppdx2">Internal hemorrhoids</item
item ID="ppdx3">Colon polyp, 6mm, ascending colon</item
</list
</text
entry
act moodCode="EVN" classCode="ACT">
templateId root="2.16.840.1.113883.10.20.22.4.51" extension="2014-06-09"/>
<!-- *** Postprocedure Diagnosis Entry *** -->
code code="59769-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Postprocedure Diagnosis"/>
entryRelationship typeCode="SUBJ">
observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
id root="ab1791b0-5c71-11db-b0de-0800200c9a66"/>
code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
text
reference value="#ppdx3"/>
</text
statusCode code="completed"/>
effectiveTime
low value="20080103"/>
</effectiveTime
value xsi:type="CD" code="103679000" codeSystem="2.16.840.1.113883.6.96" displayName="Sessile Polyp"/>
author
templateId root="2.16.840.1.113883.10.20.22.4.119"/>
time value="20050329224411+0500"/>
assignedAuthor
id extension="99999999" root="2.16.840.1.113883.4.6"/>
</assignedAuthor
</author
</observation
</entryRelationship
entryRelationship typeCode="SUBJ">
observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
id root="cd1791b0-5c71-11db-b0de-0800200c9a66"/>
code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
text
reference value="#ppdx1"/>
</text
statusCode code="completed"/>
effectiveTime
low value="20080103"/>
</effectiveTime
value xsi:type="CD" code="429430001" codeSystem="2.16.840.1.113883.6.96" displayName="diverticulosis of sigmoid"/>
author
templateId root="2.16.840.1.113883.10.20.22.4.119"/>
time value="20050329224411+0500"/>
assignedAuthor
id extension="99999999" root="2.16.840.1.113883.4.6"/>
</assignedAuthor
</author
</observation
</entryRelationship
entryRelationship typeCode="SUBJ">
observation classCode="OBS" moodCode="EVN">
<!-- Problem observation template -->
templateId root="2.16.840.1.113883.10.20.22.4.4" extension="2014-06-09"/>
id root="cd1791b0-5c71-11db-b0de-0800200c9a66"/>
code code="75321-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Clinical finding"/>
text
reference value="#ppdx2"/>
</text
statusCode code="completed"/>
effectiveTime
low value="20080103"/>
</effectiveTime
value xsi:type="CD" code="90458007" codeSystem="2.16.840.1.113883.6.96" displayName="internal hemorrhoids"/>
author
templateId root="2.16.840.1.113883.10.20.22.4.119"/>
time value="20050329224411+0500"/>
assignedAuthor
id extension="99999999" root="2.16.840.1.113883.4.6"/>
</assignedAuthor
</author
</observation
</entryRelationship
</act
</entry
</section
</component