Comment:

The sections for procedure notes as defined in cCDA are as follows. There should be some reference to them in FHIR and the ability to define a procedure with text structure one way. The two shouldn't be in different worlds--in other contexts I have seen a section for anesthesia used . I underlined the most important - note some of them are already separate fields but not free form in the FHIR procedure.

(would all work as observations too)

LOINC# LOINC Name R/O/C Cardinality Ex. UCUM Units

59843-3 Procedure note - recommended CDA sections

51847-2 Assessment+Plan R

51848-0 Assessment R

18776-5 Plan of care R

55109-3 Complications Document R

59769-0 Postprocedure diagnosis Narrative R

29554-3 Procedure description R

59768-2 Procedure indications [interpretation] Narrative R

59770-8 Procedure estimated blood loss Narrative O

59771-6 Procedure implants Narrative O

59772-4 Planned procedure Narrative O

59773-2 Procedure specimens taken Narrative O

59774-0 Procedure anesthesia Narrative O

59775-7 Procedure disposition Narrative O

59776-5 Procedure findings Narrative O

29545-1 Physical examination R

29299-5 Reason for visit C

48765-2 Allergies O

10154-3 Chief complaint Narrative - Reported O

46239-0 Chief complaint+?Reason for visit Narrative O

10157-6 Family history O

10210-3 General status O

11348-0 Past medical history O

10160-0 Medications O

29549-3 Medication administered Narrative O

47519-4 History of Procedures Document O

29762-2 Social history Narrative O

10187-3 Review of systems Narrative - Reported O