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eHN Guidelines

Data  Description Preferred Code Systems Arbetsgruppens ("Svensk") tolkning av informationselementetUtvärderingsparametrarDe nationella tjänstekontrakten

* ** A.2 Patient summary body data elements 





A.2.3.3 Procedures

Ur uppdragsbeskrivning:

•Socialstyrelsens arbete med kodverk för åtgärder (KVÅ) och mappning med internationella standarder som SNOMED CT fortsätter.
•Socialstyrelsens översättningsarbete mellan KVÅ och SNOMED-CT







A.2.3.3.1 Procedure description Describes the type of procedure SNOMED CT GPS* 
Beskrivning av hur lösningen möter EDHS krav






Bedömning






Täckningsgrad






Kvalité på informationen


A.2.3.3.2 Body site Procedure target body site SNOMED CT GPS* 
Beskrivning av hur lösningen möter EDHS krav






Bedömning






Täckningsgrad






Kvalité på informationen


A.2.3.3.3 Procedure date Date when procedure was performed ISO 8601
Beskrivning av hur lösningen möter EDHS krav






Bedömning






Täckningsgrad






Kvalité på informationen



Xt-EHR Logical Model


ShortDefinitionMinMaxType(s)Binding StrengthBinding Description    
B.1.3.4 - Procedures sectionProcedures section01Base





B.1.3.4.1 - Subsection narativeNarative content of the subsection.01string





B.1.3.4.2 - ProceduresMajor procedures.1*https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure






ShortDefinitionMinMaxType(s)Binding StrengthBinding Description   
Procedure modelC.16 - EHDS refined base model for An action that is or was performed on or for a patient0*





C.16.1 - IdentifierProcedure identifier0*Identifier




C.16.2 - DescriptionProcedure specification in string form01string




C.16.3 - CodeCode identifying the procedure01CodeableConceptpreferredSNOMED CT


C.16.4 - DateDate and time of the procedure or interval of its performance01dateTime
Period





C.16.5 - PerformerAn actor who or what performed the procedure0*Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional)




C.16.6 - Anatomic locationAnatomic location and laterality where the procedure was performed. This is the target site.0*CodeableConceptpreferredSNOMED CT, ICD-O-3


C.16.7 - ReasonThe reason why the procedure was performed.0*Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure)




C.16.8 - OutcomeThe outcome of the procedure - did it resolve the reasons for the procedure being performed?01CodeableConceptpreferredSNOMED CT


C.16.9 - ComplicationAny complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the procedure description, which will typically describe the procedure itself rather than any 'post procedure' issues.0*CodeableConceptpreferredICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed


C.16.10 - Device usedDevice used to perform the procedure0*https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice




C.16.11 - Focal deviceDevice or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.0*Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice)




C.16.12 - LocationLocation where the procedure had been performed0*https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLocation




C.16.13 - NoteAdditional information about the procedure01string




C.16.14 - PatientOn whom or on what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure.11Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLocation|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSGroup)





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