Operation Note
CDA Implementation
Guide
Version
1.0
1.0b
Date
2.6.2009
21.9.2009
Author
René Spronk
Morten S. Myhre
Comments
Initial version of the document
Added operation id to the CDA header and
body
1
Introduction ........................................................................................................................ 3
1.1 Storyboard ................................................................................................................... 3
2
CDA Header....................................................................................................................... 4
3
CDA Body ......................................................................................................................... 8
3.1 Section 1: Operation .................................................................................................... 8
3.1.1 Human readable part ............................................................................................ 8
3.1.2 Software processable part .................................................................................. 10
3.2 Section 2: Performed Procedures .............................................................................. 12
3.2.1 Human readable part .......................................................................................... 12
3.2.2 Software processable part .................................................................................. 13
3.3 Section 3: Diagnosis .................................................................................................. 14
3.3.1 Human readable part .......................................................................................... 14
3.3.2 Software processable part .................................................................................. 15
4
XML Materials................................................................................................................. 17
1 Introduction
This document contains an implementation guide for the Operation Note document as used within
Helse Vest. The Operation Note is a document created by the responsible surgeon about a surgical
operation which has been performed.
This document is an implementation guide for the Operation Note based on the HL7 version 3
Clinical Document Architecture (CDA R2) standard. A copy of the CDA standard can be found here:
http://www.hl7.org/v3ballot2009jan/html/infrastructure/cda/cda.htm
The CDA standard contains the structure of electronic documents. A CDA document contains

A Header: a class structure which identifies document metadata such as the author, the
patient, the document type, the language of the document and the time of creation of the
document.

A Body: contains a human readable text (mandatory), and (optionally) one or more class
structures which contain a ‘coded/structured’ (or: software processable) version of a (part
of) that which is sent in textual form.
The human readable parts may be rendered in a web browser using the supplied CDA.xsl style sheet.
See chapter 4 for an overview of the XML materials supplied with this implementation guide.
1.1 Storyboard
This section contains a number o
Storyboard: 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. The
document has a structure similar to the layout shown below.
Header
PasientID:
Navn:
120659-45897
Testesen, Test
Dokument oppdatert av:
Dokument signert av:
Dokument oppdatert:
Horn Arild
Horn Arild
18.05.2009 12:07
Body
Operasjon og tider
Gastro Appendectomi
Hovedoperatør: Horn Arild
Operatør:
Øvrebø Kjell
Operasjonsstue:
SOP04
Pasient mottatt
16.12.2008
06.54
Anestesi start
16.12.2008
Klar for operasjon
16.12.2008
Knivtid-start
16.12.2008
Knivtid-slutt
16.12.2008
Pasient fra operasjonsstue
16.12.2008
Pasient levert/Anestesi slutt
16.12.2008
07.06
07.21
07.22
07.34 varighet 12 min
07.54
08.01 til Postoperativ seksjon
Prosedyrer utført ved operasjon
JEA00 Lapraskopisk appendektomi (hoved)
indikasjonsdiagnose
K359 Uspesifisert akutt appendisitt
2 CDA Header
The CDA header is present in all CDA documents; it is a class structure which identifies document
metadata such as the author, the patient, the document type, the language of the document and the
time of creation of the document.
Those parts of the CDA header used by this Implementation Guide are shown below. The CDA
Header contains the following key elements:

The ClinicalDocument class which contains the ID of the document, the document type, the
document title and the document language;

The RecordTarget (and associated classes) class which identifies the patient (and subject) of
this Operation Note;

The author and legalAthenticator (and associated classes) which identify the author (the
same person as the person who signs the document, the legalAuthenticator) of the
Operation Note;

The Custodian (and associated classes) which identify the organization responsible for
archiving the ‘master version’ of this electronic document;

The component/StructuredBody/Section classes which are not actually part of the
document header, but contain the text of the body of the document.

The documentationOf which contains the ID of the operation described in the Operation
Note.
The table below contains a description of the CDA Header, starting with the XML toot element
‘clinicalDocument’.
Nesting
Level
0
1
1
1
1
Element
Attributes
clinicalDocument
@classCode, @moodCode
Contains metadata of the document, e.g. the ID of the document, the document type,
the document title and the document language.
@classCode contains the fixed value ‘DOCCLIN’; @moodCode contains the fixed value
‘EVN’.
typeId
@extension, @root
@root contains the fixed value ‘2.16.840.1.113883.1.3’, @extension contains the fixed
value ‘POCD_HD000040’.
templateId
@root
Contains the identification of this version of the ‘Operation Note CDA Implementation
Guide’ (@root = ‘2.16.578.1.34.6.1’). Note that future versions of this implementation
guide will contain a different identifier.
Id
@root, @extension
Contains a unique identifier of this instance of the Operation Note. @root identifies
(using an OID) the identification mechanism itself, and @extension the identification
assigned within that identification mechanism.
For the Helse Vest Operation System, @root will be fixed to the value
‘2.16.578.1.34.1.23.2.2’. @extension will have to be uniquely assigned for each
document.
Code
@code, @codeSystem,
@displayName
This attribute identifies the document type (Operation Note). @code contains the fixed
value ‘34874-8’, @codeSystem the fixed value ‘2.16.840.1.113883.6.1’, @displayName
1
1
1
1
1
2
3
3
4
3
4
2
2
3
4
5
5
2
the fixed value ‘Surgical operation note - by surgeon’.
Title
This element contains the title of the document as shown to a human reader. The
element has to be populated; it should contain both the patient name as well as the
operation that was carried out.
effectiveTime
@value
@value contains the date and time the document was created, in YYYYMMDDHHMM
format.
confidentialityCode
@code, @codeSystem
@code contains the fixed value ‘N’; @codeSystem contains the fixed value
‘2.16.840.1.113883.5.25’.
languageCode
@code
Identifies the language used in the document. For the Operation Note, the value of
@code should be fixed to ‘no-NO’ (Norwegian as spoken in Norway).
recordTarget
Identifies the patient (and subject) of this Operation Note.
patientRole
Identifies the Patient using an F or D number.
Id
@extension, @root
Contains exactly one Patient.id (the F-number, the D-number or the H-number –in that
order of preference-). @root contains the OID of the identification scheme; @extension
contains the identification number according to that identification scheme.
See the ‘Model Elements/Data Types/Patient and Person Identifiers’ section of the
generic ‘Helse Vest HL7 version 3 Implementation Guide’ for details.
Patient
Identifies the person that plays the role of patient.
Name
@use
Occurs one or more times. Contains the name(s) of the person.
See the ‘Model Elements/Data Types/Patient Name’ section of the generic ‘Helse Vest
HL7 version 3 Implementation Guide’ for details.
providerOrganization
Identifies the context of the patient role, which is played within the scope of Helse Vest.
Id
@extension, @root
@root contains the fixed value ‘2.16.578.1.34.1000.5’; @extension contains the fixed
value ‘983658725’.
Author
See separate description of author and legalAuthenticator below.
Custodian
Identifies the organization responsible for archiving the ‘master version’ of this
electronic document
assignedCustodian
Identifies the role of custodian as played by an organization.
representedCustodian
Identifies the organization that acts as the custodian.
Id
@root,@extension
@root contains the fixed value ‘2.16.578.1.34.1000.5’; @extension contains the fixed
value ‘983658725’.
Name
This element contains the fixed value ‘Helse Vest’.
legalAuthenticator
2
3
4
See separate description of author and legalAuthenticator below.
documentationOf
Identifies the operation which this Operation Note describes.
serviceEvent
@classCode
@classCode contains the fixed value ‘PCPR’
Id
@root, @extension
Identifies the operation described by this Operation Note. (I.e. the internal operation id
of the sending application.)
The table below contains a description of the author and legalAuthenticator XML elements within
the CDA header. These XML elements have a similar structure.
Nesting
Level
0
1
1
1
2
2
3
2
3
3
Element
Attributes
Author / legalAuthenticator
Identifies the author (who is mostly –but not always- the same person as the person
who signs the document, the legalAuthenticator) of the Operation Note.
Time
@value
The time that the document was authored/signed; @value contains the same value as
the clinicalDocument/effectiveTime/@value attribute.
signatureCode – legalAutheticator ONLY
@code
In case of legalAuthenticator: @code contains the fixed value ‘S’ (signed).
In case of author: this element doesn’t occur.
assignedAuthor / assignedEntity
In case of author: the element is named assignedAuthor.
In case of legalAuthenticator: the element is named assignedEntity.
Id
Contains the HPR number of the person who authored/signed the Operation Note.
assignedPerson
Identifies the responsible person.
Name
@use
Occurs one or more times. Contains the name(s) of the person.
See the ‘Model Elements/Data Types/Patient Name’ section of the generic ‘Helse Vest
HL7 version 3 Implementation Guide’ for details.
representedOrganization
Identifies the (responsible) organization which forms the context of the
author/legalAuthenticator of the document.
Id
@root contains the fixed value ‘2.16.578.1.34.1000.5’;
@extension contains the Enhetsregister identifier of the represented organization. If the
represented organisation is ‘Helse Bergen’ @extension contains ‘983974724’; if the
represented organization is ‘Haraldsplass Diakonale Sykehus’ @extension contains
‘984027737’.
Name
This element contains the name of the represented organization. (Examples: ‘Helse
Bergen’, or ‘Haraldsplass Diakonale Sykehus’.)
3 CDA Body
The document body consists of a list of textual sections. The information as present in the textual
sections (for the human reader) is also available in the form of HL7 version 3 class structures (for
software processing).
3.1 Section 1: Operation
This section contains a number of details about the operation which was carried out: the responsible
persons, the operation room where the procedure was carried out, as well as the starting/end time
for each of the procedure steps that form a part of the overall operation.
Below is the definition of a coding system for OperationPhases. The coding system has OID
2.16.578.1.34.5.4. The coding system contains the following coded concepts:
Code
Short description
Notes
Opphold
The entire operation as perceived by
exclusive of transportation to the operation
the patient.
room, inclusive of the transportation to the
postoperative ward.
Forberedelse Preparation for surgery
Anestesi
Anaesthesiology
Knivtid
Actual invasive procedure
Transport
Transportation to post operative ward
Note that not all of the operation phases need to occur for each operation. Example: an eye
operation doesn’t require anaesthesiology.
The relationship between the various operation phases and the start/end time of these phases is
shown in the table below.
Norwegian:
Opphold
Forberedelse
Anestesi
Knivtid
Transport
English
Stay/
Episode
Start
Preparation
Anaesthetics Surgery
Transport
Patient arrived
Aesthetic start
Ready for
operation
Operation start
Operation
finished
Patient leaving
Patient
delivered
Start
Hele
forløpet
Total
Start
Start
End
Start
End
End
End
Start
End
End
3.1.1 Human readable part
All information contained in a section should be sent in a human readable form. The CDA
standard uses a subset of XHTML to define the structure of the human readable part. See
http://www.hl7.org/v3ballot2009jan/html/infrastructure/cda/cda.htm#CDA_Section_Narra
tive_Block for the full specification.
Using the example document as defined in section 1.1 the content of this section would be
rendered as follows:
Operasjon og tider
Gastro Appendectomi
Hovedoperatør: Horn Arild
Operatør:
Øvrebø Kjell
Operasjonsstue: SOP04
Pasient 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
Pasient fra operasjonsstue
16.12.2008 07.54
Pasient levert/Anestesi slutt 16.12.2008 08.01
varighet 12 min
til Postoperativ
seksjon
Using the example document as defined in section 1.1 the human readable part of the XML
content of this section would be as shown below.
Implementers of this CDA implementation guide should use a structure similar to the one
shown below in order to ensure that all available data is properly rendered in a structure
which is familiar to the human reader.
<title>Operasjon og tider </title>
<text> Gastro Appendectomi <br/><br/>
<table border="1">
<tbody>
<tr>
<td>Hovedoperatør:</td>
<td>
<content styleCode="Bold">Horn Arild</content>
</td>
</tr>
<tr>
<td>Operatør:</td>
<td>
<content styleCode="Bold">Øvrebø Kjell</content>
</td>
</tr>
<!-- Repeat structure below zero or more times, once for each assistant -->
<tr>
<td>Operasjonsstue:</td>
<td>
<content styleCode="Bold">SOP04</content>
</td>
</tr>
</tbody>
</table>
<br/><br/>
<table border="1">
<tbody>
<tr>
<td>Pasient mottatt</td>
<td>16.12.2008</td>
<td>06.54</td>
</tr>
<tr>
<td>Anestesi start</td>
<td>16.12.2008</td>
<td>07.06</td>
</tr>
<tr>
<td>Klar for operasjon</td>
<td>16.12.2008</td>
<td>07.21</td>
</tr>
<tr>
<td>Knivtid-start</td>
<td>16.12.2008</td>
<td>07.22</td>
</tr>
<tr>
<td>Knivtid-slutt</td>
<td>16.12.2008</td>
<td>07.34</td>
<td>varighet <content styleCode="Bold">12</content> min</td>
</tr>
<tr>
<td>Pasient fra operasjonsstue</td>
<td>16.12.2008</td>
<td>07.54</td>
</tr>
<tr>
<td>Pasient levert/Anestesi slutt</td>
<td>16.12.2008</td>
<td>08.01</td>
<td>til <content styleCode="Bold">Postoperativ
seksjon</content></td>
</tr>
</tbody>
</table>
</text>
3.1.2 Software processable part
The information present in the textual section is also made available in software processable form.
Two entries are used to model the details of the procedure and the timing of the operation phases.
Nesting
Level
0
1
2
2
2
3
Element
Attributes
Component
Contains a section of the document body
Section
The section, comprised of both a textual as well as a software processable part.
Code
@code, @codeSystem
Identifies the section type: “surgical operation note findings”.
@code contains the fixed value ‘10215-2’; @codeSystem contains the fixed value
‘2.16.840.1.113883.6.1’.
Textual body
The textual (human readable) content of the section, see section 3.2.1 for details
entry
@typeCode
The first entry contains the details of the operation and its phases.
@typeCode contains the fixed value ‘DRIV’
Act
@classCode, @moodCode
This class represents the ‘care relationship’ the surgical department has with the patient
(in other words: the operation) during which one or more procedures have been carried
out. @classCode contains the fixed value ‘PCPR’, @moodCode the fixed value ‘EVN’.
Id
@root, @extension
4
4
4
5
5
6
4
5
5
6
4
5
6
Identifies the operation described by this Operation Note. (I.e. the internal operation id
of the sending application.)
Code
@code, @codeSystem
Identifies the phase of the operation, in this case the entire stay of the patient at the
surgical ward. The code is from the OperationsPhases table as documented in section
3.1.
@code contains the fixed value ‘Opphold’; @codeSystem contains the fixed value
‘2.16.578.1.34.5.4’.
effectiveTime
@low, @high
@low contains the start data/time of the patient stay (Norwegian: Opphold); @high
contains the end date/time of the patient stay. See section 3.1 for a description of the
relationship between the start/end times of the various phases of the operation.
participant
@typeCode
May occur one or more times, once for each (assisting-) surgeon. If the participant is the
main/responsible surgeon, @typeCode should be valued with PPRF (Primary Performer).
If the participant is an assisting surgeon, @typeCode should be valued with ‘SPRF’
(Secondary Performer).
Each operation should have exactly one PPRF, and zero or more SPRF participations.
Id
Contains the HPR number of the person who participated in the operation.
playingEntity
Name
@use
Occurs one or more times. Contains the name(s) of the person.
See the ‘Model Elements/Data Types/Patient Name’ section of the generic ‘Helse Vest
HL7 version 3 Implementation Guide’ for details.
participant
@typeCode
Used to identify the operating room where the operation took place. @typeCode
conatins the fixed value ‘LOC’.
Note to implementers: note that participant may also occur as an XML element with the
typeCode ‘PPRF’ or ‘SPRF’ as documented above.
Id
@root, @extension
Contains the identification of the operating room – its RESH Identifier. @root contains
the fixed value ‘2.16.578.1.34.1000.4’, @extension the RESH identifier of the operating
room.
playingEntity
Identifies the physical location where the operation took place.
Name
The name of the operating room.
entryRelationship
@typeCode
May occur one or more times, each occurrence contains the details of one of the phases
of the operation as defined in the OperationsPhases table as documented in section 3.1.
Not all phases listed in the table need occur in the context of each operation.
@typeCode contains the fixed value ‘COMP’
Procedure
@classCode, @moodCode
Contains the details of a single phase of the operation.
@classCode contains the fixed value ‘PROC’, @moodCode the fixed value ‘EVN’.
Code
@code, @codeSystem
Identifies the phase of the operation. The code is from the OperationsPhases table as
documented in section 3.1.
6
2
3
4
4
4
5
6
6
7
@code contains a value from the OperationsPhases table; @codeSystem contains the
fixed value ‘2.16.578.1.34.5.4’.
effectiveTime
@low, @high
@low contains the start data/time of this phase of the operation; @high contains the
end date/time.
See section 3.1 for a description of the relationship between the start/end times of the
various phases of the operation.
entry
@typeCode
The second entry contains the details of the transportation of the patient, after the
operation, to the postoperative ward.
@typeCode contains the fixed value ‘DRIV’.
act
@classCode, @moodCode
Contains the details of the transportation of the patient.
Code
@code, @codeSystem
Identifies the type of activity. The @code is ‘Transportation’; @codeSystem contains the
fixed value ‘2.16.578.1.34.5.4’.
effectiveTime
@low, @high
@low contains the start data/time of the postoperative transportation activity; @high
contains the end date/time.
See section 3.1 for a description of the relationship between the start/end times of the
various phases of the operation.
Participant
@typeCode
Contains the details of the destination location.
@typeCode contains the fixed value ‘LOC’.
participantRole
@classCode
@classCode contains the fixed value ‘SDLOC’.
Id
@root, @extension
Contains the identification of the postoperative ward– its RESH Identifier. @root
contains the fixed value ‘2.16.578.1.34.1000.4’, @extension the RESH identifier of the
postoperative ward.
playingEntity
Identifies the physical location that is the destination of the transportation activity.
Name
The name of the postoperative ward.
3.2 Section 2: Performed Procedures
This section contains a list of procedures that were carried out during the operation. One of the
procedures will be identified as being the ‘main’ procedure.
3.2.1 Human readable part
All information contained in a section should be sent in a human readable form. The CDA
standard uses a subset of XHTML to define the structure of the human readable part. See
http://www.hl7.org/v3ballot2009jan/html/infrastructure/cda/cda.htm#CDA_Section_Narra
tive_Block for the full specification.
Using the example document as defined in section 1.1 the content of this section would be
rendered as follows:
Prosedyrer utført ved operasjon
o JEA00 Lapraskopisk appendektomi (hoved)
Using the example document as defined in section 1.1 the human readable part of the XML
content of this section would be as shown below.
Implementers of this CDA implementation guide should use a structure similar to the one
shown below in order to ensure that all available data is properly rendered in a structure
which is familiar to the human reader.
text>
<list>
<item>
<content ID="p1">JEA00 Lapraskopisk appendektomi (hoved)</content>
</item>
</list>
</text>
Note that the use of <content ID=> will be explained in the next section.
3.2.2 Software processable part
The information present in the textual section is also made available in software processable form.
Nesting
Level
0
1
2
2
2
3
4
Element
Attributes
Component
Contains a section of the document body
Section
The section is comprised of both a textual as well as a software processable part.
Code
@code, @codeSystem
Identifies the section type: “procedures”.
@code contains the fixed value ‘29554-3’; @codeSystem contains the fixed value
‘2.16.840.1.113883.6.1’.
Textual body
The textual (human readable) content of the section, see section 3.2.1 for details
entry
@typeCode
@typeCode contains the fixed value ‘DRIV’
procedure
@classCode, @moodCode
This class represents the surgical part of the operation, during which one or more
procedures have been carried out. @classCode contains the fixed value ‘PROC’,
@moodCode the fixed value ‘EVN’.
Code
@code, @codeSystem
Identifies the phase of the operation, i.e. the surgery performed (Norwegian: Knivtid).
The code is from the OperationsPhases table as documented in section 3.1.
@code contains the fixed value ‘Knivtid’; @codeSystem contains the fixed value
4
5
6
7
8
9
‘2.16.578.1.34.5.4’.
entryRelationship
@typeCode
Occurs repeatedly, once for each procedure carried out during the surgery.
sequenceNumber
@value
Used to distinguish the relative importance of the procedures; if @value 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.
procedure
@classCode, @moodCode
Contains the details of one of the procedures carried out during the surgery phase of the
operation.
Code
@code, @codeSystem
Identifies the type of procedure carried out. @codeSystem either has to be
‘2.16.578.1.12.4.1.1.7210’ (NCPM Norwegian) or ‘2.16.578.1.12.4.1.1.7220’ (NSMP
Norwegian). @code contains the procedure code according to one of these coding
systems.
originalText
Contains a link from the coded diagnosis to the text in the human readable part of the
section.
Reference
The value of @value, for this coded diagnosis, is the same as the value of the contented
in the human readable part of the section. @value is preceeded by the ‘#’ sign to denote
the fact that it is a reference.
Example (human readable part):
<content ID="p1">JEA00 Lapraskopisk appendektomi </content>
Example (related software processable part):
<originalText>
<reference value="#p1"/>
</originalText>
3.3 Section 3: Diagnosis
This section contains the list of diagnosis codes that were the underlying reason for performing the
operation. The section is optional – there may not be any known/relevant diagnosis codes related to
the operation. If diagnosis codes are know they have to be sent.
3.3.1 Human readable part
All information contained in a section should be sent in a human readable form. The CDA
standard uses a subset of XHTML to define the structure of the human readable part. See
http://www.hl7.org/v3ballot2009jan/html/infrastructure/cda/cda.htm#CDA_Section_Narra
tive_Block for the full specification.
Using the example document as defined in section 1.1 the content of this section would be
rendered as follows:
Indikasjonsdiagnoser
o K359 Uspesifisert akutt appendisitt
Using the example document as defined in section 1.1 the human readable part of the XML
content of this section would be as shown below.
Implementers of this CDA implementation guide should use a structure similar to the one
shown below in order to ensure that all available data is properly rendered in a structure
which is familiar to the human reader.
<title>Indikasjonsdiagnoser</title>
<text>
<list>
<item>
<content ID="d1">K359 Uspesifisert akutt appendisitt</content>
</item>
</list>
</text>
Note that the use of <content ID=> will be explained in the next section.
3.3.2 Software processable part
The information present in the textual section is also made available in software processable form.
Nesting
Level
0
1
2
2
2
3
4
5
6
Element
Attributes
Component
Contains a section of the document body
Section
The section is comprised of both a textual as well as a software processable part.
Code
@code, @codeSystem
Identifies the section type: “preoperative diagnosis”.
@code contains the fixed value ‘10219-4’; @codeSystem contains the fixed value
‘2.16.840.1.113883.6.1’.
Textual body
The textual (human readable) content of the section, see section 3.3.1 for details
Entry
@typeCode
@typeCode contains the fixed value ‘DRIV’
Observation
This class may occur 1 or more times, once for each diagnosis.
code
@code, @codeSystem
@codeSystem contains the OID for ICD-10 NO, ‘2.16.578.1.12.4.1.1.7110’. @code
contains the diagnosis code.
originalText
Contains a link from the coded diagnosis to the text in the human readable part of the
section.
Reference
@value
The value of @value, for this coded diagnosis, is the same as the value of the contented
in the human readable part of the section. @value is preceeded by the ‘#’ sign to denote
the fact that it is a reference.
Example (human readable part):
<content ID="d1">K359 Uspesifisert akutt appendisitt</content>
Example (related software processable part):
<originalText>
<reference value="#d1"/>
</originalText>
4
statusCode
@code
@code contains the fixed value ‘completed’, to denote that this is a ‘final/complete
diagnosis’.
4 XML Materials
This implementation guide is accompanied by a number of supporting XML files:

One or more CDA examples in the /XML directory

CDA.xsl, a style sheet that can be used to render the human readable parts of the CDA document

The XML Schema in de /Schemas and /Coreschemas directories.