ASTM E2182 Operative Report Description

References

ASTM E2182 Clinical Header http://www.openhealth.org/ASTM/clinical.header

Clinical Body

ASTM E2183 conformant documents have a clinical header and a clinical body. The clinical header is constant across the E2182 documents. The clinical body is document type dependent. For an operative report the body has XML elements corresponding to common information items in an operative report. Names of 'service actors' such as the Attending Surgeon are incorporated into the clinical header.

clinical.body.model = (
	 preoperative.diagnosis,
	 postoperative.diagnosis,
	 procedure,
	 anesthesia,
	 indications,
	 prep?,
	 medications?,
	 description,
	 findings?,
	 specimens?,
	 closure?,
	 complications?,
	 pathology.intraoperative?,
	 pathology.permanent?,
	 drains?,
	 counts?,
	 estimated.blood.loss?,
	 fluids?,
	 patient.condition?,
	 disposition?,
	 followup?
)
start = element operative.report {astm.document.attrib,clinical.header,clinical.body}
clinical.body = element clinical.body{
	ch.attrib,
	clinical.body.model
}

Elements having content "text" consist of text alone. Elements having content "astm.content" may be a combination of text and XHTML content.

  1. preoperative.diagnosis = element preoperative.diagnosis {astm.content.attrib, text}
  2. postoperative.diagnosis = element postoperative.diagnosis {astm.content.attrib, text}
  3. procedure = element procedure {astm.content.attrib, text}
  4. anesthesia = element anesthesia {astm.content.attrib, text}
  5. indications = element indications {astm.content.attrib, astm.content}
  6. prep = element prep {astm.content.attrib, astm.content}
  7. medications = element medications {astm.content.attrib,(astm.content | medication)*}
  8. medication = element medication{astm.content.attrib, text}
  9. description = element description {astm.content.attrib, astm.content}
  10. findings = element findings {astm.content.attrib, astm.content}
  11. specimens = element specimens {astm.content.attrib, astm.content}
  12. closure = element closure {astm.content.attrib, astm.content}
  13. complications = element complications {astm.content.attrib, astm.content}
  14. drains = element drains {astm.content.attrib, astm.content}
  15. counts = element counts {astm.content.attrib, astm.content}
  16. pathology.intraoperative = element pathology.intraoperative{astm.content.attrib, astm.content}
  17. pathology.permanent = element pathology.permanent {astm.content.attrib, astm.content}
  18. estimated.blood.loss = element estimated.blood.loss {astm.content.attrib, text}
  19. fluids = element fluids{(astm.content.attrib,fluid)*}
  20. fluid = element fluid {
	astm.content.attrib,
	attribute status{"given"|"loss"},
	attribute volume{text}?,
	text}
  21. patient.condition = element patient.condition {astm.content.attrib, astm.content}
  22. disposition = element disposition {astm.content.attrib, astm.content}
  23. followup = element followup {astm.content.attrib, astm.content}

preoperative.diagnosis

Text, may be an XLink. the preoperative diagnosis. Codes corresponding to the diagnosis may also be included as coded.value s within the clinical.header.

postoperative.diagnosis

Text, may be an XLink. the postoperative diagnosis. Coded values may also be incorporated in the clinical header.

procedure

Text, may be an XLink. the procedure performed. Coded values e.g. CPT, may also be incorporated in the clinical header.