├── Allscripts Samples ├── Enterprise EHR │ └── readme.txt ├── Professional EHR │ └── readme.txt ├── Sunrise Clinical Manager │ └── readme.txt └── Internal Test with MU 2 data │ └── readme.txt ├── Kinsights Samples └── README.md ├── README.md ├── mTuitive OpNote Samples ├── README.md ├── colonoscopy.xml ├── hernia.xml ├── cataract.xml ├── breast surgery.xml └── knee.xml ├── HL7 Samples ├── UD.sample.xml └── DIR.sample.xml └── Kareo Samples └── Kareo_CCD_export_Joey_Miller.ccd /Allscripts Samples/Enterprise EHR/readme.txt: -------------------------------------------------------------------------------- 1 | The files in this folder came from an Allscripts EHR product. -------------------------------------------------------------------------------- /Allscripts Samples/Professional EHR/readme.txt: -------------------------------------------------------------------------------- 1 | The files in this folder came from an Allscripts EHR product. -------------------------------------------------------------------------------- /Allscripts Samples/Sunrise Clinical Manager/readme.txt: -------------------------------------------------------------------------------- 1 | The files in this folder came from an Allscripts EHR product. -------------------------------------------------------------------------------- /Allscripts Samples/Internal Test with MU 2 data/readme.txt: -------------------------------------------------------------------------------- 1 | The files in this folder came from an internal testing tool generating documents using MU 2 test data. -------------------------------------------------------------------------------- /Kinsights Samples/README.md: -------------------------------------------------------------------------------- 1 | # Kinsights C-CDA Sample 2 | 3 | Kinsights allows its users to export their records via a [bbClear](https://blue-button.github.io/bbClear/) HTML document, which contains the raw data in the form of an embedded C-CDA XML document. 4 | 5 | The basic structure of the bbClear document is: 6 | 7 | 8 | ... 9 | ... 10 | 11 | 14 | 15 | The XML data is extractable by the end user in-browser, and this XML file is included in this directory as well. 16 | 17 | We hope other C-CDA parsers will eventually recognize the more patient-friendly bbClear wrapper and allow it as an acceptable format for C-CDA importing when the end-user is offered the option to upload C-CDA data. 18 | -------------------------------------------------------------------------------- /README.md: -------------------------------------------------------------------------------- 1 | # Share Your C-CDA with the SMART Community 2 | * By copy/paste: http://bit.ly/contribute-ccda *or* 3 | * By forking this repository and sumitting a pull request 4 | 5 | # Sample CCDA Documents 6 | ### (Consolidated Clinical Document Architecture) 7 | 8 | ### What 9 | This is a repository to collect **Sample CCDA Documents**. (No protected health information.) These samples are available under the [Creative Commons Attribution 4.0 license](https://creativecommons.org/licenses/by/4.0/). 10 | 11 | ### Why? 12 | *Lots* of people will be implementing CCDA very soon; many have already started. 13 | But there are big questions about how to do what, and while an excellent 14 | implementation guide is a must, examples matter too. The community would 15 | benefit immensely from a public collection of examples that can be: 16 | * dissected, 17 | * discussed, and 18 | * corrected over time. 19 | 20 | The goals are to provide: 21 | * examples for the developer community 22 | * a platform to identify and correct implementation errors 23 | * a public arena to identify areas of ambiguity and variability 24 | 25 | ### Why not? 26 | If there are barriers (organizational, technical, cultural, or otherwise), 27 | can we break them down? [Discuss](https://github.com/chb/sample_ccdas/issues). 28 | 29 | ### How? 30 | *All comers welcome*! To contribute samples, just: 31 | 1. Fork this repository to your GitHub account 32 | 2. Add an example file 33 | 3. Issue a GitHub "Pull request" 34 | 35 | ... or just share by e-mail with `joshua dot mandel at childrens.harvard.edu` 36 | 37 | ### Fine print 38 | Sample documents should be available under an open license and should not 39 | involve PHI. Ideally these documents would represent actual output of 40 | real export pipelines. 41 | -------------------------------------------------------------------------------- /mTuitive OpNote Samples/README.md: -------------------------------------------------------------------------------- 1 | #mTuitive OpNote CCDA Samples 2 | 3 | These samples are intended to comply with the [Consolidated CDA Implementation Guide (IG)](http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258). 4 | 5 | [mTuitive OpNote](http://mtuitive.com/opnote) is a web-based application that lets surgeons easily create 6 | structured operative reports instead of narrative dictation. This data is useful for research, clinical automation, 7 | billing, etc. 8 | 9 | CCDA is intended to provide some guidance about structured various clinical documents and is already very useful 10 | for exchanging operative reports. The choice of open CDA templates proved very helpful, allowing us to include additional 11 | sections not covered by the IG and entries not specified by the IG. 12 | 13 | ##Areas for Improvement 14 | The current implementation by mTuitive is useful as-is, but there are several areas that could use additional refinement: 15 | * Encode diagnoses as ICD10 or SNOMED. Since ICD9 is used in production, that's what we've provided here. 16 | * More entry level section templates 17 | * H&P, Discharge Summary, and Procedure Note implementations 18 | * LOINC codes for all section templates 19 | 20 | ##Suggestions for CCDA 2.0 21 | 22 | The difference between operative note and procedure note is murky. We would be in favor of consolidating them into 23 | one template or providing applicable CPT codes for each. 24 | 25 | Real-world operative reports often document multiple procedures. The specification clearly only allows one instance of 26 | some important required sections, which makes this difficult. In mTuitive's production application, each procedure has 27 | its own instance of some fields. 28 | 29 | To implement this with CCDA, we include a serviceEvent for each procedure. Within the document body, we use a container 30 | section that corresponds to each serviceEvent being documented. Each container section includes a ProcedureContext 31 | template to set the context for sub-sections within its scope to the appropriate procedure. This works but is not 32 | strictly compliant because there may be multiple operative description or laterality fields in the document. 33 | We felt this was preferable to concatenating all of the relevant fields into one text block. 34 | 35 | For example: 36 | 37 |
38 | Operative Description 39 | 40 |
41 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) (66984) 42 | 43 | 44 | 45 | 46 | 47 | 48 | 49 | 50 | 51 |
52 | Laterality 53 | 54 | 55 | Bilateral 56 | 57 | 58 |
59 | 60 | 61 |
62 | 63 | 64 | Operation Description 65 | 66 | 67 | Lieberman lid speculum placed between eyelids 68 | Superior temporal incision performed in beveled three-stage maneuver 69 | ... 70 | ##Validation 71 | 72 | There are two known validation errors found using the [Lantana CCDA validator](https://www.lantanagroup.com/validator/connectathon.jsp). 73 | This tool was helpful for finding cda schema and ccda schematron violations with a single tool. 74 | 75 | 1. An unknown address is flagged as an error. When using , the validator still complains 76 | about missing child elements. [Others](https://www.projects.openhealthtools.org/sf/go/artf3450?returnUrlKey=1353511042478) 77 | seem to have experienced the same issue. 78 | >If country is US, this addr SHALL contain exactly one [1..1] state, which SHALL be selected from ValueSet 2.16.840.1.113883.3.88.12.80.1 StateValueSet DYNAMIC (CONF:5402). 79 | >Location: /ClinicalDocument[1] 80 | >Test: (cda:recordTarget/cda:patientRole/cda:addr[cda:country='US' or cda:country='USA']) and cda:recordTarget/cda:patientRole/cda:addr/cda:state 81 | 82 | 2. As noted above, multiple procedure descriptions are used and scoped to the appropriate serviceEvent using the 83 | Procedure Context template. The validator complains because there are multiple procedure description elements where 84 | only 1 is allowed. The schema will hopefully be relaxed in a future version to allow 1 or more procedure descriptions. 85 | >SHALL contain exactly one [1..1] Procedure Description Section (templateId:2.16.840.1.113883.10.20.22.2.27) (CONF:9896). 86 | >Location: /ClinicalDocument[1] 87 | >Test: count(//cda:section[cda:templateId/@root='2.16.840.1.113883.10.20.22.2.27'])=1 88 | 89 | The [SMART C-CDA Scorecard](http://ccda-scorecard.smartplatforms.org/) ranks each document at 72%. 100% of applicable best practices are met. The documents are 90 | scored lower for missing structured vitals, which we suspect is a mistake because our documents do not include vitals. 91 | This tool was particularly helpful in finding coding inconsitencies, such as mismatched LOINC display names. 92 | 93 | 94 | 95 | -------------------------------------------------------------------------------- /HL7 Samples/UD.sample.xml: -------------------------------------------------------------------------------- 1 | 2 | 3 | 13 | 17 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | Discharge Summary (UD) 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 | 45 | 46 | 47 | 48 | 49 | 17 Daws Rd. 50 | Blue Bell 51 | MA 52 | 02368 53 | US 54 | 55 | 56 | 57 | 58 | 59 | 60 | 61 | Mr. 62 | Adam 63 | Frankie 64 | 65 | Everyman 66 | 67 | 68 | 69 | 70 | 71 | 72 | 73 | 74 | 75 | 76 | 77 | 17 Daws Rd. 78 | Blue Bell 79 | MA 80 | 02368 81 | US 82 | 83 | 84 | 85 | 86 | 87 | Ralph 88 | Relative 89 | 90 | 91 | 92 | 93 | 94 | 95 | MA 96 | 02368 97 | USA 98 | 99 | 100 | 101 | 102 | 103 | 104 | 105 | 106 | 107 | 108 | 109 | Good Health Clinic 110 | 111 | 112 | 21 North Ave 113 | Burlington 114 | MA 115 | 02368 116 | USA 117 | 118 | 119 | 120 | 121 | 122 | 141 | 142 | 143 | 144 | 145 | 21 North Ave. 146 | Burlington 147 | MA 148 | 02368 149 | USA 150 | 151 | 152 | 153 | 154 | Henry 155 | Seven 156 | 157 | 158 | 159 | 160 | 161 | 162 | 163 | 164 | 21 North Ave. 165 | Burlington 166 | MA 167 | 02368 168 | USA 169 | 170 | 171 | 172 | 173 | Henry 174 | Seven 175 | 176 | 177 | 178 | 179 | 180 | 181 | 182 | 183 | 184 | 185 | Rose 186 | Everyman 187 | 188 | 189 | 190 | 191 | 192 | 193 | 194 | 195 | Good Health Clinic 196 | 197 | 198 | 17 Daws Rd. 199 | Blue Bell 200 | MA 201 | 02368 202 | USA 203 | 204 | 205 | 206 | 207 | 208 | 209 | 210 | 211 | Henry 212 | Seven 213 | 214 | 215 | 216 | Good Health Clinic 217 | 218 | 219 | 220 | 221 | 241 | 242 | 262 | 269 | 270 | 271 | 272 | 273 | 274 | 275 | 276 | 277 | 278 | 287 | 288 | -------------------------------------------------------------------------------- /Kareo Samples/Kareo_CCD_export_Joey_Miller.ccd: -------------------------------------------------------------------------------- 1 | <effectiveTime value="20140531151542.706-0700"/><confidentialityCode/><languageCode code="en-US"/><recordTarget><patientRole><id assigningAuthorityName="KAREO EHR" extension="28366080" root="ProviderID"/><addr use="HP"><streetAddressLine>26 N. Martin Street</streetAddressLine><streetAddressLine/><city>Los Angeles</city><state>CA</state><postalCode>90005</postalCode><country>United States of America</country></addr><telecom/><patient><name><given>JOEY</given><given>null</given><family>MILLER</family></name><!--HITSP/C83 requires patient administrative gender, e.g. M, F, I (indeterminate)--><administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" codeSystemName="HL7 AdministrativeGender" displayName="Male"/><birthTime value="19471010"/><!--HITSP/C83 requires patient marital status - if known, e.g. S, M, D--><maritalStatusCode codeSystemName="HL7 Marital status"/><!--HITSP/C32 requires patient languages spoken - if known.--><languageCommunication><templateId assigningAuthorityName="HITSP/C83" root="2.16.840.1.113883.3.88.11.83.2"/><templateId assigningAuthorityName="IHE/PCC" root="1.3.6.1.4.1.19376.1.5.3.1.2.1"/><languageCode code="en-US"/></languageCommunication></patient></patientRole></recordTarget><author><time value="20140531151542.706-0700"/><assignedAuthor><id/><addr/><telecom/><assignedPerson><name/></assignedPerson><representedOrganization><name/><telecom/><addr/></representedOrganization></assignedAuthor></author><custodian><assignedCustodian><representedCustodianOrganization><id/><name/><telecom/><addr/></representedCustodianOrganization></assignedCustodian></custodian><legalAuthenticator><time value="20140531151542.706-0700"/><signatureCode code="S"/><assignedEntity><id nullFlavor="NI"/><addr/><telecom/><assignedPerson><name/></assignedPerson><representedOrganization><name>KAREO EHR</name><telecom/><addr/></representedOrganization></assignedEntity></legalAuthenticator><!--HITSP/C32 requires one or more support modules (i.e. participant) - if known; if not known, the participant element(s) may be removed in their entirety. However, many medical facilities require recording of the Next-of-Kin (NOK). The following shows how to represent that information in the participant element.--><component><structuredBody><component><!--Allergies--><section><templateId assigningAuthorityName="HITSP/C83" root="2.16.840.1.113883.3.88.11.83.102"/><templateId assigningAuthorityName="IHE PCC" root="1.3.6.1.4.1.19376.1.5.3.1.3.13"/><templateId assigningAuthorityName="HL7 CCD" root="2.16.840.1.113883.10.20.1.2"/><!--Allergies/Reactions section template--><code code="48765-2" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Allergies"/><title>Allergies and Adverse Reactions
TypeSubstanceReactionStatus
DRUGsulfa drugdrug rash Active
sulfa drug
Problems
ProblemEffective DatesProblem Status
HypothyroidismAug 05, 2012ACTIVE
Acute bronchitisOct 02, 2012ACTIVE
Medications
MedicationStrengthFormSig TextDatesStatus
acetaminophen-aspirin buffered 250 mg-250 mg oral tabletbuffered 250 mg-250 mgtabletActive
POtabletacetaminophen-aspirin
Immunizations
VaccineDateStatus
Pneumococcal (PCV, PPSV)May 15, 2014Completed
Pneumococcal (PCV, PPSV)
Diagnostic Results
TestValueRangeDate
Vital Signs
NameValueDate
MAY 15, 2014, 12:53 AM
Body height71 [in_us]MAY 15, 2014
Body weight measured160 [lb_av]MAY 15, 2014
Respiratory rate20 /minMAY 15, 2014
Body temperature98 [degF]MAY 15, 2014
Heart rate80 /minMAY 15, 2014
Oxygen saturation in capillary blood by oximetry100 %MAY 15, 2014
Systolic blood pressure120 mm[Hg]MAY 15, 2014
Diastolic BP0 mm[Hg]MAY 15, 2014
 -------------------------------------------------------------------------------- /mTuitive OpNote Samples/colonoscopy.xml: -------------------------------------------------------------------------------- 1 | 2 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | Operative Report 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | Lary 32 | 33 | Byrd 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 57 | 58 | 59 | 60 | 61 | 62 | Default Center 63 | 64 | 65 | 66 | 67 | 68 | 70 | 71 | 85 | 88 | 89 | 90 | 91 | 92 | 93 | 94 | 95 | 96 | 97 | Surgeon 98 | 99 | 103 | 104 | 105 | 106 | 107 | 108 | 109 | 110 | 111 | Gastroenterology 112 | Surgery 113 | 114 | 115 | 116 | 117 | 118 | 119 | 120 | 121 | 122 | 123 | 124 |
125 | 126 | 127 | Operations Performed 128 | 129 | 130 | Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) (45378) 131 | 132 | 133 |
134 | 135 | 136 |
137 | Surgeon 138 | 139 | 140 | Gastroenterology Surgery, MD 141 | 142 | 143 |
144 | 145 | 146 |
147 | Date of surgery 148 | 149 | 150 | Thursday, December 20, 2012 151 | 152 | 153 |
154 | 155 | 156 | 157 |
158 | 159 | 160 | Preoperative Diagnosis 161 | 162 | 163 | Internal hemorrhoids without mention of complication (455.0) 164 | 165 | 166 | 167 | 168 | 169 | 170 | 171 | 172 | 173 | 174 | 175 | 176 | 177 | 178 | 179 | 180 | 181 | 182 | 183 | 184 | 185 | 186 |
187 | 188 | 189 |
190 | 191 | 192 | Postoperative Diagnosis 193 | 194 | 195 | Internal hemorrhoids without mention of complication (455.0) 196 | 197 | 198 | 199 | 200 | 201 | 202 | 203 | 204 | 205 | 206 | 207 | 208 | 209 | 210 | 211 | 212 | 213 | 214 | 215 | 216 | 217 | 218 |
219 | 220 | 221 | 222 |
223 | Indications for Surgery 224 | 225 |
226 | 227 | 228 | Indications 229 | 230 | 231 | See diagnosis 232 | 233 | 234 |
235 | 236 |
237 | 238 | 239 | 240 |
241 | Risk and Consent 242 | 243 |
244 | Risk Factors 245 | 246 | 247 | None 248 | 249 | 250 |
251 | 252 | 253 |
254 | ASA Physical Status 255 | 256 | 257 | Class I. Normal healthy patient 258 | 259 | 260 |
261 | 262 | 263 |
264 | Informed Consent 265 | 266 | 267 | Yes: Indications for surgical procedure, risks, benefits, possible complications explained to patient including alternatives in treatment. Patient had the chance to ask questions and all were answered to their satisfaction. Patient understood and gave consent. 268 | 269 | 270 |
271 | 272 |
273 | 274 | 275 | 276 |
277 | Operative Findings 278 | 279 |
280 | 281 | 282 | Operative Findings 283 | 284 | 285 | Normal Colon 286 | No Polyps 287 | No signs of Cancer 288 | 289 | 290 |
291 | 292 |
293 | 294 | 295 | 296 |
297 | Preparation 298 | 299 |
300 | 301 | 302 | Anesthesia 303 | 304 | 305 | Topical 306 | 307 | 308 |
309 | 310 | 311 |
312 | Position 313 | 314 | 315 | Prone 316 | 317 | 318 |
319 | 320 | 321 |
322 | Surgical Field 323 | 324 | 325 | Antiseptic applied 326 | 327 | 328 |
329 | 330 | 331 |
332 | Draping 333 | 334 | 335 | Prepped and draped in standard sterile fashion 336 | 337 | 338 |
339 | 340 | 341 |
342 | Pre-medication 343 | 344 | 345 | Propofol given in divided doses and titrated to effect 346 | Total dose of 400 mg Propofol 347 | 348 | 349 |
350 | 351 |
352 | 353 | 360 | 361 |
362 | Operative Description 363 | 364 |
365 | Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) (45378) 366 | 367 | 368 | 369 | 370 | 371 | 372 | 373 | 374 | 375 |
376 | 377 | 378 | Operation Description 379 | 380 | 381 | Olympus colonoscope used 382 | Colonoscope inserted 383 | Scope advanced through the colon 384 | Scope advanced through sigmoid to the cecum 385 | Colon examined 386 | No Polyps found 387 | Scope withdrawn and retroflexed in the rectum 388 | Small internal hemorrhoids identified 389 | Hemorrhoids removed 390 | Time withdrawal 391 | Over 10 minutes 392 | 393 | 394 |
395 | 396 |
397 | 398 |
399 | 400 | 402 | 403 |
404 | Discharge and Condition 405 | 406 |
407 | 408 | 409 | Estimated blood loss 410 | 411 | 412 | 0 mL or less 413 | 414 | 415 |
416 | 417 | 418 |
419 | Sponge/needle/instrument count 420 | 421 | 422 | Correct x 2 423 | 424 | 425 |
426 | 427 | 428 |
429 | Discharge 430 | 431 | 432 | Surgical day care recovery 433 | 434 | 435 |
436 | 437 | 438 |
439 | 440 | 441 | Condition 442 | 443 | 444 | Stable 445 | 446 | 447 |
448 | 449 | 450 |
451 | DVT Prophylaxis 452 | 453 | 454 | Not applicable 455 | 456 | 457 |
458 | 459 | 460 |
461 | 462 | 463 | Specimen 464 | 465 | 466 | None 467 | 468 | 469 |
470 | 471 | 472 |
473 | 474 | 475 | Complications 476 | 477 | 478 | No complications 479 | 480 | 481 |
482 | 483 | 484 |
485 | Comments 486 | 487 | 488 | Patient tolerated procedure well. 489 | 490 | 491 |
492 | 493 |
494 | 495 | 496 | 497 |
498 | Signature 499 | 500 | 501 | Signed by Gastroenterology Surgery, MD at 8:26 PM Thursday, December 20, 2012 502 | 503 | 504 |
505 | 506 | 507 | 508 | -------------------------------------------------------------------------------- /mTuitive OpNote Samples/hernia.xml: -------------------------------------------------------------------------------- 1 | 2 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | Operative Report 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | John 32 | 33 | Wayne 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 57 | 58 | 59 | 60 | 61 | 62 | Default Center 63 | 64 | 65 | 66 | 67 | 68 | 70 | 71 | 85 | 88 | 89 | 90 | 91 | 92 | 93 | 94 | 95 | 96 | 97 | Surgeon 98 | 99 | 103 | 104 | 105 | 106 | 107 | 108 | 109 | 110 | 111 | General 112 | Surgery 113 | 114 | 115 | 116 | 117 | 118 | 119 | 120 | 121 | 122 | 123 | 124 |
125 | 126 | 127 | Operations Performed 128 | 129 | 130 | Repair initial inguinal hernia, age 5 years or older; reducible (49505) 131 | 132 | 133 |
134 | 135 | 136 |
137 | Surgeon 138 | 139 | 140 | General Surgery, MD 141 | 142 | 143 |
144 | 145 | 146 |
147 | Assistants 148 | 149 | 150 | Pain Management, 151 | 152 | 153 |
154 | 155 | 156 |
157 | Date of surgery 158 | 159 | 160 | Tuesday, June 25, 2013 161 | 162 | 163 |
164 | 165 | 166 | 167 |
168 | 169 | 170 | Preoperative Diagnosis 171 | 172 | 173 | Inguinal hernia without mention of obstruction or gangrene, unilateral or unspecified, (not specified as recurrent) (550.90) 174 | 175 | 176 | 177 | 178 | 179 | 180 | 181 | 182 | 183 | 184 | 185 | 186 | 187 | 188 | 189 | 190 | 191 | 192 | 193 | 194 | 195 | 196 |
197 | 198 | 199 |
200 | 201 | 202 | Postoperative Diagnosis 203 | 204 | 205 | Inguinal hernia without mention of obstruction or gangrene, unilateral or unspecified, (not specified as recurrent) (550.90) 206 | 207 | 208 | 209 | 210 | 211 | 212 | 213 | 214 | 215 | 216 | 217 | 218 | 219 | 220 | 221 | 222 | 223 | 224 | 225 | 226 | 227 | 228 |
229 | 230 | 231 | 232 |
233 | Indications for Surgery 234 | 235 |
236 | 237 | 238 | Indications 239 | 240 | 241 | Pain 242 | Discomfort 243 | Enlarging mass 244 | 245 | 246 |
247 | 248 |
249 | 250 | 251 | 252 |
253 | Risk and Consent 254 | 255 |
256 | Risk Factors 257 | 258 | 259 | Increased body mass index 260 | 261 | 262 |
263 | 264 | 265 |
266 | ASA Physical Status 267 | 268 | 269 | Class II. Patient with mild systemic disease 270 | 271 | 272 |
273 | 274 | 275 |
276 | Informed Consent 277 | 278 | 279 | Yes: Indications for surgical procedure, risks, benefits, possible complications explained to patient including alternatives in treatment. Patient had the chance to ask questions and all were answered to their satisfaction. Patient understood and gave consent. 280 | 281 | 282 |
283 | 284 |
285 | 286 | 287 | 288 |
289 | Operative Findings 290 | 291 |
292 | 293 | 294 | Operative Findings 295 | 296 | 297 | Indirect hernia 298 | 299 | 300 |
301 | 302 |
303 | 304 | 305 | 306 |
307 | Preparation 308 | 309 |
310 | 311 | 312 | Anesthesia 313 | 314 | 315 | Local 316 | 317 | 318 |
319 | 320 | 321 |
322 | Position 323 | 324 | 325 | Supine 326 | 327 | 328 |
329 | 330 | 331 |
332 | Surgical Field 333 | 334 | 335 | Clipped 336 | Antiseptic applied 337 | Betadine 338 | 339 | 340 |
341 | 342 | 343 |
344 | Draping 345 | 346 | 347 | Appropriate draping 348 | 349 | 350 |
351 | 352 | 353 |
354 | Pre-medication 355 | 356 | 357 | Antibiotic administered within one hour of surgical incision 358 | 359 | 360 |
361 | 362 |
363 | 364 | 371 | 372 |
373 | Operative Description 374 | 375 |
376 | Repair initial inguinal hernia, age 5 years or older; reducible (49505) 377 | 378 | 379 | 380 | 381 | 382 | 383 | 384 | 385 | 386 |
387 | Laterality 388 | 389 | 390 | Left 391 | 392 | 393 |
394 | 395 | 396 |
397 | 398 | 399 | Operation Description 400 | 401 | 402 | Incision was made and carried down to the external oblique fascia 403 | Fascia was incised in the direction of its fibers to to external inguinal ring 404 | Cord was mobilized and encircled 405 | Nerves were carefully preserved 406 | Vas deferens and vessels carefully preserved intact 407 | Hernia sac exposed, adequately visualized and identified 408 | Sac carefully dissected from surrounding structures 409 | Sac ligated and redundant portion excised 410 | Hernia sac and contents reduced 411 | Marlex mesh plug and patch applied 412 | Hemostasis assured 413 | Wound irrigated 414 | Incision closed in layers 415 | Appropriate dressing applied 416 | 417 | 418 |
419 | 420 |
421 | 422 |
423 | 424 | 426 | 427 |
428 | Discharge and Condition 429 | 430 |
431 | 432 | 433 | Estimated blood loss 434 | 435 | 436 | 25 mL or less 437 | 438 | 439 |
440 | 441 | 442 |
443 | Sponge/needle/instrument count 444 | 445 | 446 | Correct x 2 447 | 448 | 449 |
450 | 451 | 452 |
453 | Discharge 454 | 455 | 456 | Surgical day care recovery 457 | 458 | 459 |
460 | 461 | 462 |
463 | 464 | 465 | Condition 466 | 467 | 468 | Stable 469 | 470 | 471 |
472 | 473 | 474 |
475 | DVT Prophylaxis 476 | 477 | 478 | Anti Embolism Stockings (TED Stockings) 479 | 480 | 481 |
482 | 483 | 484 |
485 | 486 | 487 | Specimen 488 | 489 | 490 | Sac sent to pathology 491 | 492 | 493 |
494 | 495 | 496 |
497 | 498 | 499 | Complications 500 | 501 | 502 | No complications 503 | 504 | 505 |
506 | 507 | 508 |
509 | Comments 510 | 511 | 512 | Patient tolerated procedure well. Follow up in 2 weeks. 513 | 514 | 515 |
516 | 517 |
518 | 519 | 520 | 521 |
522 | Signature 523 | 524 | 525 | Signed by General Surgery, MD at 1:37 PM Tuesday, June 25, 2013 526 | 527 | 528 |
529 | 530 | 531 | 532 | -------------------------------------------------------------------------------- /mTuitive OpNote Samples/cataract.xml: -------------------------------------------------------------------------------- 1 | 2 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | Operative Report 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | John 32 | 33 | Wayne 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 57 | 58 | 59 | 60 | 61 | 62 | Default Center 63 | 64 | 65 | 66 | 67 | 68 | 70 | 71 | 85 | 88 | 89 | 90 | 91 | 92 | 93 | 94 | 95 | 96 | 97 | Surgeon 98 | 99 | 103 | 104 | 105 | 106 | 107 | 108 | 109 | 110 | 111 | Ophthalmology 112 | Surgery 113 | 114 | 115 | 116 | 117 | 118 | 119 | 120 | 121 | 122 | 123 | 124 |
125 | 126 | 127 | Operations Performed 128 | 129 | 130 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) (66984) 131 | 132 | 133 |
134 | 135 | 136 |
137 | Surgeon 138 | 139 | 140 | Ophthalmology Surgery, MD 141 | 142 | 143 |
144 | 145 | 146 |
147 | Date of surgery 148 | 149 | 150 | Friday, March 22, 2013 151 | 152 | 153 |
154 | 155 | 156 | 157 |
158 | 159 | 160 | Preoperative Diagnosis 161 | 162 | 163 | Nuclear sclerosis (366.16) 164 | 165 | 166 | 167 | 168 | 169 | 170 | 171 | 172 | 173 | 174 | 175 | 176 | 177 | 178 | 179 | 180 | 181 | 182 | 183 | 184 | 185 | 186 |
187 | 188 | 189 |
190 | 191 | 192 | Postoperative Diagnosis 193 | 194 | 195 | Nuclear sclerosis (366.16) 196 | 197 | 198 | 199 | 200 | 201 | 202 | 203 | 204 | 205 | 206 | 207 | 208 | 209 | 210 | 211 | 212 | 213 | 214 | 215 | 216 | 217 | 218 |
219 | 220 | 221 | 222 |
223 | Indications for Surgery 224 | 225 |
226 | 227 | 228 | Indications 229 | 230 | 231 | See diagnosis 232 | 233 | 234 |
235 | 236 |
237 | 238 | 239 | 240 |
241 | Risk and Consent 242 | 243 |
244 | Risk Factors 245 | 246 | 247 | None 248 | 249 | 250 |
251 | 252 | 253 |
254 | ASA Physical Status 255 | 256 | 257 | See anesthesia report 258 | 259 | 260 |
261 | 262 | 263 |
264 | Informed Consent 265 | 266 | 267 | Yes: Indications for surgical procedure, risks, benefits, possible complications explained to patient including alternatives in treatment. Patient had the chance to ask questions and all were answered to their satisfaction. Patient understood and gave consent. 268 | 269 | 270 |
271 | 272 |
273 | 274 | 275 | 276 |
277 | Operative Findings 278 | 279 |
280 | 281 | 282 | Operative Findings 283 | 284 | 285 | No unusual findings 286 | 287 | 288 |
289 | 290 |
291 | 292 | 293 | 294 |
295 | Preparation 296 | 297 |
298 | 299 | 300 | Anesthesia 301 | 302 | 303 | Monitored Anesthesia Care (MAC) 304 | Topical 305 | 306 | 307 |
308 | 309 | 310 |
311 | Position 312 | 313 | 314 | Supine 315 | 316 | 317 |
318 | 319 | 320 |
321 | Surgical Field 322 | 323 | 324 | Operating microscope drawn into place 325 | 326 | 327 |
328 | 329 | 330 |
331 | Draping 332 | 333 | 334 | Prepped and draped in standard sterile fashion 335 | 336 | 337 |
338 | 339 | 340 |
341 | Pre-medication 342 | 343 | 344 | Not applicable 345 | 346 | 347 |
348 | 349 |
350 | 351 | 358 | 359 |
360 | Operative Description 361 | 362 |
363 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) (66984) 364 | 365 | 366 | 367 | 368 | 369 | 370 | 371 | 372 | 373 |
374 | Laterality 375 | 376 | 377 | Bilateral 378 | 379 | 380 |
381 | 382 | 383 |
384 | 385 | 386 | Operation Description 387 | 388 | 389 | Lieberman lid speculum placed between eyelids 390 | Superior temporal incision performed in beveled three-stage maneuver 391 | 3.0 mm keratome blade used 392 | Watertight wound created 393 | Intraocular nonpreserved lidocaine 0.2 cc used to complete anesthesia 394 | Viscoelastic applied 395 | Viscoelastic applied 396 | Separate paracentesis site prepared in anticipation of two-handed phaco-technique 397 | Continuous tear anterior capsulorrhexis performed with Utrata forceps 398 | Hydrodissection completed 399 | 30-gauge cannula used on a syringe with balanced salt solution 400 | Phacoemulsification performed by chop technique 401 | Viscoelastic reapplied to anterior chamber every 10 units of CDE for 10.41 total units of energy 402 | I&A used to remove remaining cortex 403 | Posterior capsule polished under low vacuum 404 | Posterior capsule remained clear and intact 405 | SN60WF intraocular lens of 22.5 diopters in power inserted 406 | Lens inserted through 2.4 mm incision into capsular bag 407 | Lens rotated to achieve stability and centration 408 | Residual viscoelastic removed with irrigation-aspiration tip 409 | Miostat used to constrict pupil and hydrate wounds 410 | Vigamox 0.1 cc injected intracamerally 411 | Wound checked and watertight 412 | Vigamox and Timolol applied topically to eye 413 | Gentamycin ophthalmic ointment applied 414 | Lid speculum removed 415 | 416 | 417 |
418 | 419 |
420 | 421 |
422 | 423 | 425 | 426 |
427 | Discharge and Condition 428 | 429 |
430 | 431 | 432 | Estimated blood loss 433 | 434 | 435 | 0 mL or less 436 | 437 | 438 |
439 | 440 | 441 |
442 | Sponge/needle/instrument count 443 | 444 | 445 | Correct x 2 446 | 447 | 448 |
449 | 450 | 451 |
452 | Discharge 453 | 454 | 455 | Home 456 | 457 | 458 |
459 | 460 | 461 |
462 | 463 | 464 | Condition 465 | 466 | 467 | Stable 468 | 469 | 470 |
471 | 472 | 473 |
474 | DVT Prophylaxis 475 | 476 | 477 | Not applicable 478 | 479 | 480 |
481 | 482 | 483 |
484 | 485 | 486 | Specimen 487 | 488 | 489 | None 490 | 491 | 492 |
493 | 494 | 495 |
496 | 497 | 498 | Complications 499 | 500 | 501 | No complications 502 | 503 | 504 |
505 | 506 | 507 |
508 | Comments 509 | 510 | 511 | Patient tolerated procedure well. 512 | 513 | Follow up in 48 hours Patient to resume preoperative eye drops and oral medications 514 | 515 | 516 |
517 | 518 |
519 | 520 | 521 | 522 |
523 | Signature 524 | 525 | 526 | Signed by Ophthalmology Surgery, MD at 10:55 AM Friday, March 22, 2013 527 | 528 | 529 |
530 | 531 | 532 | 533 | -------------------------------------------------------------------------------- /HL7 Samples/DIR.sample.xml: -------------------------------------------------------------------------------- 1 | 2 | 3 | 10 | 14 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | Chest X-Ray, PA and LAT View 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 17 Daws Rd. 39 | Blue Bell 40 | MA 41 | 02368 42 | USA 43 | 44 | 45 | 46 | 47 | Adam 48 | Everyman 49 | 50 | 51 | 52 | 53 | 54 | 55 | 56 | 57 | 58 | 59 | 17 Daws Rd. 60 | Blue Bell 61 | MA 62 | 02368 63 | USA 64 | 65 | 66 | 67 | 68 | Ralph 69 | Relative 70 | 71 | 72 | 73 | 74 | 75 | 76 | MA 77 | 02368 78 | USA 79 | 80 | 81 | 82 | 83 | 84 | 85 | 86 | 87 | 88 | 89 | 90 | Good Health Clinic 91 | 92 | 93 | 21 North Ave 94 | Burlington 95 | MA 96 | 02368 97 | USA 98 | 99 | 100 | 101 | 102 | 103 | 122 | 123 | 124 | 125 | 126 | 21 North Ave. 127 | Burlington 128 | MA 129 | 02368 130 | USA 131 | 132 | 133 | 134 | 135 | Henry 136 | Seven 137 | 138 | 139 | 140 | 141 | 142 | 143 | 144 | 145 | Good Health Clinic 146 | 147 | 148 | 17 Daws Rd. 149 | Blue Bell 150 | MA 151 | 02368 152 | USA 153 | 154 | 155 | 156 | 157 | 158 | 159 | 160 | 161 | Henry 162 | Seven 163 | 164 | 165 | 166 | Good Health Clinic 167 | 168 | 169 | 170 | 171 | 191 | 192 | 212 | 213 | 214 | 215 | 216 | 217 | 218 | 219 | 220 | 221 | 222 | 223 | 224 | 225 | 226 | 227 | 228 | 229 | 230 | 231 | 232 | 233 | 234 | 235 | 236 | 237 | 238 | 239 | Christine 240 | Cure 241 | MD 242 | 243 | 244 | 245 | 246 | 247 | 248 | 249 | 250 | 251 | 252 | 253 | 254 | 255 | 256 | 257 | 258 | 259 | 260 | 261 | 262 | 263 | 264 | 265 | 266 | 267 | 268 | Dr. 269 | Fay 270 | Family 271 | 272 | 273 | 274 | 275 | 276 | 277 | 278 | 279 | 280 | 285 |
286 | 287 | 288 | 289 | 294 | 295 | 296 | 297 | 298 | 303 | 304 | 305 | 306 | 307 | 308 | 309 | 310 | 311 | 312 | 317 | 318 | 319 | 320 | 321 | 322 | 323 | 324 | 325 | 326 | 327 | 328 | 329 | 330 | 331 | 332 | 333 | 334 | 335 | 336 | 337 | 338 | 339 | 340 | 341 | 342 | 343 | 344 | 345 | 346 |
347 | 352 | 353 | 354 | 360 |
361 | 362 | Indications for Procedure 363 | Suspected lung tumor 364 |
365 | 370 | 371 | 372 | 377 |
378 | 379 | History 380 | 381 | 382 | History 383 | Sore throat. 384 | 385 | 386 | 387 | 388 | 389 | 390 | 391 | 392 | 393 | 394 | 395 | 396 |
397 | 402 | 403 | 404 | 409 |
410 | 411 | 412 | Findings 413 | 414 | 415 | Finding 416 | The cardiomediastinum is within normal limits. The 417 | trachea is midline. The previously described opacity at the medial 418 | right lung base has cleared. There are no new infiltrates. There is 419 | a new round density at the left hilus, superiorly (diameter about 420 | 45mm). A CT scan is recommended for further evaluation. The pleural 421 | spaces are clear. The visualized musculoskeletal structures and the 422 | upper abdomen are stable and unremarkable. 423 | 424 | 425 | Diameter 426 | 45mm 427 | 428 | 429 | Source of Measurement 430 | 431 | Chest_PA 432 | 433 | 434 | 435 | 436 | 437 | 438 | 439 | 440 | 441 | 442 | 443 | 444 | 445 | 446 | 447 | 448 | 449 | 450 | 451 | 452 | 453 | 454 | 455 | 456 | 457 | 458 | 459 | 460 | 461 | 462 | 463 | 464 | 465 | 466 | 467 | 468 | 469 | 470 | 471 | 472 | 473 | 474 | 475 | 476 | 477 | 478 | 479 | 480 | 481 | 482 | 483 | 484 | 485 | 486 | 487 | 488 | 489 | 490 | 491 | 492 | 493 | 494 | 495 | 496 | 497 | 498 | 499 | 500 | 501 | 502 | 503 |
504 | 509 | 510 | 511 | 516 |
517 | 518 | Impressions 519 | 520 | 521 | Impression 522 | No acute cardiopulmonary process. Round density in 523 | left superior hilus, further evaluation with CT is recommended as 524 | underlying malignancy is not excluded. 525 | 526 | 527 | 528 | 529 | 530 | 531 | 532 | 533 | 534 | 535 | 536 | 537 | 538 | 539 | 540 | 541 | 542 | 543 | 544 | 545 | 546 | 547 |
548 | 553 | 554 | 555 | 556 | 557 | -------------------------------------------------------------------------------- /mTuitive OpNote Samples/breast surgery.xml: -------------------------------------------------------------------------------- 1 | 2 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | Operative Report 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | Dee 32 | 33 | Fault 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 57 | 58 | 59 | 60 | 61 | 62 | Default Center 63 | 64 | 65 | 66 | 67 | 68 | 70 | 71 | 85 | 88 | 89 | 90 | 91 | 92 | 93 | 94 | 95 | 96 | 97 | Surgeon 98 | 99 | 103 | 104 | 105 | 106 | 107 | 108 | 109 | 110 | 111 | General 112 | Surgery 113 | 114 | 115 | 116 | 117 | 118 | 119 | 120 | 121 | 122 | 123 | 124 | 125 | 126 | 127 | 128 | Surgeon 129 | 130 | 134 | 135 | 136 | 137 | 138 | 139 | 140 | 141 | 142 | General 143 | Surgery 144 | 145 | 146 | 147 | 148 | 149 | 150 | 151 | 152 | 153 | 154 | 155 | 156 | 157 | 158 | 159 | Surgeon 160 | 161 | 165 | 166 | 167 | 168 | 169 | 170 | 171 | 172 | 173 | General 174 | Surgery 175 | 176 | 177 | 178 | 179 | 180 | 181 | 182 | 183 | 184 | 185 | 186 |
187 | 188 | 189 | Operations Performed 190 | 191 | 192 | Injection procedure; radioactive tracer for identification of sentinel node (38792) 193 | Biopsy or excision of lymph node(s); open, deep axillary node(s) (38525) 194 | Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); (19301) 195 | 196 | 197 |
198 | 199 | 200 |
201 | Surgeon 202 | 203 | 204 | General Surgery, MD 205 | 206 | 207 |
208 | 209 | 210 |
211 | Assistants 212 | 213 | 214 | Neuro Surgery, MD 215 | 216 | 217 |
218 | 219 | 220 |
221 | Date of surgery 222 | 223 | 224 | Tuesday, June 25, 2013 225 | 226 | 227 |
228 | 229 | 230 | 231 |
232 | 233 | 234 | Preoperative Diagnosis 235 | 236 | 237 | Malignant neoplasm of upper-inner quadrant of female breast (174.2) 238 | 239 | 240 | 241 | 242 | 243 | 244 | 245 | 246 | 247 | 248 | 249 | 250 | 251 | 252 | 253 | 254 | 255 | 256 | 257 | 258 | 259 | 260 |
261 | 262 | 263 |
264 | 265 | 266 | Postoperative Diagnosis 267 | 268 | 269 | Malignant neoplasm of upper-inner quadrant of female breast (174.2) 270 | 271 | 272 | 273 | 274 | 275 | 276 | 277 | 278 | 279 | 280 | 281 | 282 | 283 | 284 | 285 | 286 | 287 | 288 | 289 | 290 | 291 | 292 |
293 | 294 | 295 | 296 |
297 | Indications for Surgery 298 | 299 |
300 | 301 | 302 | Indications 303 | 304 | 305 | Biopsy proven malignancy 306 | 307 | 308 |
309 | 310 |
311 | 312 | 313 | 314 |
315 | Risk and Consent 316 | 317 |
318 | Risk Factors 319 | 320 | 321 | None 322 | 323 | 324 |
325 | 326 | 327 |
328 | ASA Physical Status 329 | 330 | 331 | Class II. Patient with mild systemic disease 332 | 333 | 334 |
335 | 336 | 337 |
338 | Informed Consent 339 | 340 | 341 | Yes: Indications for surgical procedure, risks, benefits, possible complications explained to patient including alternatives in treatment. Patient had the chance to ask questions and all were answered to their satisfaction. Patient understood and gave consent. 342 | 343 | 344 |
345 | 346 |
347 | 348 | 349 | 350 |
351 | Operative Findings 352 | 353 |
354 | 355 | 356 | Operative Findings 357 | 358 | 359 | Palpable mass excised with grossly clear margins, confirmed by pathology 360 | Sentinel node negative by frozen section 361 | 362 | 363 |
364 | 365 |
366 | 367 | 368 | 369 |
370 | Preparation 371 | 372 |
373 | 374 | 375 | Anesthesia 376 | 377 | 378 | General 379 | 380 | 381 |
382 | 383 | 384 |
385 | Position 386 | 387 | 388 | Supine 389 | 390 | 391 |
392 | 393 | 394 |
395 | Surgical Field 396 | 397 | 398 | Antiseptic applied 399 | 400 | 401 |
402 | 403 | 404 |
405 | Draping 406 | 407 | 408 | Appropriate draping 409 | 410 | 411 |
412 | 413 | 414 |
415 | Pre-medication 416 | 417 | 418 | Antibiotic 419 | 420 | 421 |
422 | 423 |
424 | 425 | 432 | 433 |
434 | Operative Description 435 | 436 |
437 | Injection procedure; radioactive tracer for identification of sentinel node (38792) 438 | 439 | 440 | 441 | 442 | 443 | 444 | 445 | 446 | 447 |
448 | Laterality 449 | 450 | 451 | Right 452 | 453 | 454 |
455 | 456 | 457 |
458 | 459 | 460 | Operation Description 461 | 462 | 463 | 5cc of lymphazurin injected into subareolar position and massaged for 5 minutes 464 | 465 | 466 |
467 | 468 |
469 | 470 | 471 |
472 | Biopsy or excision of lymph node(s); open, deep axillary node(s) (38525) 473 | 474 | 475 | 476 | 477 | 478 | 479 | 480 | 481 | 482 |
483 | Laterality 484 | 485 | 486 | Right 487 | 488 | 489 |
490 | 491 | 492 |
493 | 494 | 495 | Operation Description 496 | 497 | 498 | Wound infiltrated with local anesthetic 499 | Appropriate dressing applied 500 | Incision made in the usual and sterile fashion 501 | Tissue dissected to node 502 | Node removed 503 | No other blue-stained nodes noted 504 | No suspicious or palpable nodes noted 505 | Wound closed in layers 506 | 507 | 508 |
509 | 510 |
511 | 512 | 513 |
514 | Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); (19301) 515 | 516 | 517 | 518 | 519 | 520 | 521 | 522 | 523 | 524 |
525 | Laterality 526 | 527 | 528 | Right 529 | 530 | 531 |
532 | 533 | 534 |
535 | 536 | 537 | Operation Description 538 | 539 | 540 | Natural skin line incision performed 541 | Flaps were raised 542 | Mass excised with appropriate margins 543 | Tumor bed marked with radiographic clips 544 | Hemostasis assured 545 | Wound irrigated 546 | Wound infiltrated with local anesthetic 547 | Incision closed in layers 548 | Appropriate dressing applied 549 | 550 | 551 |
552 | 553 |
554 | 555 |
556 | 557 | 559 | 560 |
561 | Discharge and Condition 562 | 563 |
564 | 565 | 566 | Estimated blood loss 567 | 568 | 569 | 25 mL or less 570 | 571 | 572 |
573 | 574 | 575 |
576 | Sponge/needle/instrument count 577 | 578 | 579 | Correct x 2 580 | 581 | 582 |
583 | 584 | 585 |
586 | Discharge 587 | 588 | 589 | Surgical day care recovery 590 | 591 | 592 |
593 | 594 | 595 |
596 | 597 | 598 | Condition 599 | 600 | 601 | Stable 602 | 603 | 604 |
605 | 606 | 607 |
608 | DVT Prophylaxis 609 | 610 | 611 | Anti Embolism Stockings (TED Stockings) 612 | 613 | 614 |
615 | 616 | 617 |
618 | 619 | 620 | Specimen 621 | 622 | 623 | Sentinel node, negative on frozen section 624 | Lumpectomy specimen oriented for margins 625 | 626 | 627 |
628 | 629 | 630 |
631 | 632 | 633 | Complications 634 | 635 | 636 | No complications 637 | 638 | 639 |
640 | 641 | 642 |
643 | Comments 644 | 645 | 646 | Patient tolerated procedure well. 647 | 648 | 649 |
650 | 651 |
652 | 653 | 654 | 655 |
656 | Signature 657 | 658 | 659 | Signed by General Surgery, MD at 1:39 PM Tuesday, June 25, 2013 660 | 661 | 662 |
663 | 664 | 665 | 666 | 667 | -------------------------------------------------------------------------------- /mTuitive OpNote Samples/knee.xml: -------------------------------------------------------------------------------- 1 | 2 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | Operative Report 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | Skip 32 | 33 | Manam 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 57 | 58 | 59 | 60 | 61 | 62 | Default Center 63 | 64 | 65 | 66 | 67 | 68 | 70 | 71 | 85 | 88 | 89 | 90 | 91 | 92 | 93 | 94 | 95 | 96 | 97 | Surgeon 98 | 99 | 103 | 104 | 105 | 106 | 107 | 108 | 109 | 110 | 111 | Orthopedic 112 | Surgery 113 | 114 | 115 | 116 | 117 | 118 | 119 | 120 | 121 | 122 | 123 | 124 | 125 | 126 | 127 | 128 | Surgeon 129 | 130 | 134 | 135 | 136 | 137 | 138 | 139 | 140 | 141 | 142 | Orthopedic 143 | Surgery 144 | 145 | 146 | 147 | 148 | 149 | 150 | 151 | 152 | 153 | 154 | 155 |
156 | 157 | 158 | Operations Performed 159 | 160 | 161 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction (29888) 162 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed (29881) 163 | 164 | 165 |
166 | 167 | 168 |
169 | Surgeon 170 | 171 | 172 | Orthopedic Surgery, MD 173 | 174 | 175 |
176 | 177 | 178 |
179 | Date of surgery 180 | 181 | 182 | Friday, June 21, 2013 183 | 184 | 185 |
186 | 187 | 188 | 189 |
190 | 191 | 192 | Preoperative Diagnosis 193 | 194 | 195 | Sprain and strain of cruciate ligament of knee (844.2) 196 | Derangement of posterior horn of medial meniscus (717.2) 197 | 198 | 199 | 200 | 201 | 202 | 203 | 204 | 205 | 206 | 207 | 208 | 209 | 210 | 211 | 212 | 213 | 214 | 215 | 216 | 217 | 218 | 219 | 220 | 221 | 222 | 223 | 224 | 225 | 226 | 227 | 228 | 229 | 230 | 231 | 232 |
233 | 234 | 235 |
236 | 237 | 238 | Postoperative Diagnosis 239 | 240 | 241 | Derangement of posterior horn of medial meniscus (717.2) 242 | Sprain and strain of cruciate ligament of knee (844.2) 243 | 244 | 245 | 246 | 247 | 248 | 249 | 250 | 251 | 252 | 253 | 254 | 255 | 256 | 257 | 258 | 259 | 260 | 261 | 262 | 263 | 264 | 265 | 266 | 267 | 268 | 269 | 270 | 271 | 272 | 273 | 274 | 275 | 276 | 277 | 278 |
279 | 280 | 281 | 282 |
283 | Indications for Surgery 284 | 285 |
286 | 287 | 288 | Indications 289 | 290 | 291 | Acute Knee Injury 292 | Knee Pain, Acute 293 | Swelling 294 | Stiffness 295 | Instability 296 | 297 | 298 |
299 | 300 |
301 | 302 | 303 | 304 |
305 | Risk and Consent 306 | 307 |
308 | Risk Factors 309 | 310 | 311 | None 312 | 313 | 314 |
315 | 316 | 317 |
318 | ASA Physical Status 319 | 320 | 321 | Class I. Normal healthy patient 322 | 323 | 324 |
325 | 326 | 327 |
328 | Informed Consent 329 | 330 | 331 | Yes: Indications for surgical procedure, risks, benefits, possible complications explained to patient including alternatives in treatment. Patient had the chance to ask questions and all were answered to their satisfaction. Patient understood and gave consent. 332 | 333 | 334 |
335 | 336 |
337 | 338 | 339 | 340 |
341 | Operative Findings 342 | 343 |
344 | 345 | 346 | Operative Findings 347 | 348 | 349 | Suprapatellar pouch revealed hemosiderin staining 350 | Posterior surface of patella normal 351 | Femoral trochlea normal 352 | Complete tear of ACL 353 | Tibial end remaining 354 | Posterior horn of medial meniscus tear noted 355 | 356 | 357 |
358 | 359 |
360 | 361 | 362 | 363 |
364 | Preparation 365 | 366 |
367 | 368 | 369 | Anesthesia 370 | 371 | 372 | General 373 | Regional, Peripheral Nerve Blocks 374 | 375 | 376 |
377 | 378 | 379 |
380 | Position 381 | 382 | 383 | Supine 384 | 385 | 386 |
387 | 388 | 389 |
390 | Surgical Field 391 | 392 | 393 | Clipped 394 | 1% tincture of Iodine 395 | 396 | 397 |
398 | 399 | 400 |
401 | Draping 402 | 403 | 404 | Draped in a Sterile Fashion 405 | 406 | 407 |
408 | 409 | 410 |
411 | Pre-medication 412 | 413 | 414 | Femoral nerve block 415 | 1 Gm Ancef 416 | Prophylactic antibiotic 417 | 418 | 419 |
420 | 421 |
422 | 423 | 430 | 431 |
432 | Operative Description 433 | 434 |
435 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction (29888) 436 | 437 | 438 | 439 | 440 | 441 | 442 | 443 | 444 | 445 |
446 | Laterality 447 | 448 | 449 | Right 450 | 451 | 452 |
453 | 454 | 455 |
456 | 457 | 458 | Operation Description 459 | 460 | 461 | Tourniquet Used 462 | Tourniquet inflated to 250mm Hg 463 | Portal incision performed on either side of the patellar tendon 464 | Arthrex Video and Crossfire Systems Used 465 | Arthroscope with video camera inserted through lateral portal 466 | Digital Images recorded for documentation purposes 467 | Debridement of ACL Remnant 468 | Limited lateral notchplasty performed 469 | Small transverse incision of proximal tibia performed 470 | Tibial alignment guide used 471 | Drill hole made over guidewire 472 | 10mm Drill Hole made 473 | Knee shaved to remove debris from around drill site and soft tissue 474 | Edges smoothed with rasp 475 | Knee placed in hyperflexion position 476 | Femoral alignment guide used 477 | Guidewire placed through tibial drill hole, through isometric point of femur 478 | 10mm drill hole made to a depth of 35 mm 479 | Notch made at 12 o'clock position 480 | Grafton injected into femoral drill hole 481 | 10mm Tibialis Allograft Used 482 | Tibialis Allograft pulled into knee joint 483 | Arthex Femoral Screw Inserted 9x23mm 484 | Knee extended to 30 degrees 485 | Notch made at 12 o'clock position in tibial drill hole 486 | Nitinol wire inserted 487 | Bioabsorbable screw inserted over a nitinol wire 488 | Arthrex Bioabsorbable Screw 11x28mm Used 489 | Purchase of tibia secured 490 | Full range of motion with complete extension present 491 | Complete Correction of Lachman sign noted 492 | Hemostasis assured 493 | Knee irrigated 494 | Wounds closed with 3-0 Prolene 495 | Sterile compressive dressing applied 496 | 497 | 498 |
499 | 500 |
501 | 502 | 503 |
504 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed (29881) 505 | 506 | 507 | 508 | 509 | 510 | 511 | 512 | 513 | 514 |
515 | Laterality 516 | 517 | 518 | Right 519 | 520 | 521 |
522 | 523 | 524 |
525 | 526 | 527 | Operation Description 528 | 529 | 530 | Partial meniscectomy, Medial 531 | Posterior horn tear resected 532 | Stable Rim Present 533 | 534 | 535 |
536 | 537 |
538 | 539 |
540 | 541 | 543 | 544 |
545 | Discharge and Condition 546 | 547 |
548 | 549 | 550 | Estimated blood loss 551 | 552 | 553 | 10 mL or less 554 | 555 | 556 |
557 | 558 | 559 |
560 | Sponge/needle/instrument count 561 | 562 | 563 | Correct x 2 564 | 565 | 566 |
567 | 568 | 569 |
570 | Discharge 571 | 572 | 573 | Surgical day care recovery 574 | 575 | 576 |
577 | 578 | 579 |
580 | 581 | 582 | Condition 583 | 584 | 585 | Stable 586 | 587 | 588 |
589 | 590 | 591 |
592 | DVT Prophylaxis 593 | 594 | 595 | Not applicable 596 | 597 | 598 |
599 | 600 | 601 |
602 | 603 | 604 | Specimen 605 | 606 | 607 | Sent to pathology 608 | Bone 609 | Synovium 610 | Cartilage 611 | 612 | 613 |
614 | 615 | 616 |
617 | 618 | 619 | Complications 620 | 621 | 622 | No complications 623 | 624 | 625 |
626 | 627 |
628 | 629 | 630 | 631 |
632 | Signature 633 | 634 | 635 | Signed by Orthopedic Surgery, MD at 2:29 PM Wednesday, July 17, 2013 636 | 637 | 638 |
639 | 640 | 641 | 642 | --------------------------------------------------------------------------------