Surgery Document
Source Object: Surgery Document
Overview and Usage: The "Surgery Document" source object contains data related to surgery documents and information. Surgery documents are essential in healthcare to record and manage surgical procedures and their associated details. Below are key components of the "Surgery Document" source object:
- Action Note: Notes or actions related to the surgery document.
- Alarm Days: The number of days for alarm or notification purposes.
- Appointment ID: A unique identifier for the associated appointment.
- Approved Date: The date when the surgery document was approved.
- Assigned To: The person or entity assigned to the surgery document.
- Clinical Provider ID: A unique identifier for the clinical provider associated with the surgery.
- Clinical Provider Name: The name of the clinical provider.
- Created Date Time: The date and time when the surgery document was created.
- Created User: The user who created the surgery document.
- Date of Service: The date when the surgery service took place.
- Declined Reason Code: A code indicating the reason for declining the surgery document.
- Declined Reason Description: A description of the reason for declining the surgery document.
- Declined Reason Code Set: The code set or category for declined reasons.
- Declined Reason Text: Additional text describing the declined reason.
- Deleted Date Time: The date and time when the surgery document was deleted.
- Department ID: A unique identifier for the department associated with the surgery document.
- Document Description: A description of the surgery document.
- Document Route: The route or method of sending the document.
- Document Source: The source of the surgery document.
- Document Subclass: The subclass or category of the document.
- Document Type: The type or category of the document.
- Document Type ID: A unique identifier for the document type.
- Encounter ID: A unique identifier for the associated encounter.
- External Accession ID: An external identifier for accessing the document.
- External Note: Additional notes related to external access.
- Facility ID: A unique identifier for the facility associated with the surgery.
- Internal Accession ID: An internal identifier for accessing the document.
- Internal Note: Additional internal notes related to the document.
- Last Modified Date Time: The date and time when the surgery document was last modified.
- Last Modified User: The user who last modified the document.
- Observation Date Time: The date and time of the surgical observation.
- Surgery ID: A unique identifier for the surgery document.
- Order Type: The type or category of the surgery order.
- Out of Network Referral Reason ID: A unique identifier for the reason for out-of-network referral.
- Patient Case ID: A unique identifier for the patient's case.
- Perform Date: The date when the surgery procedure was performed.
- Place of Service: The location or place where the surgery took place.
- Place of Service ID: A unique identifier for the place of service.
- Priority: The priority level of the surgery document
- Receive Note: Notes received regarding the surgery document.
- Requested Visits: The number of visits requested.
- Schedule Within: The time frame within which scheduling is required.
- Specimen Collected By: The entity or person who collected the specimen.
- Specimen Collection Date Time: The date and time of specimen collection.
- Specimen Collection Site: The site or location of specimen collection.
- Specimen Notes: Notes related to the specimen.
- Specimen Source ID: A unique identifier for the specimen source.
- Specimen Source Name: The name of the specimen source.
- Standing Order Duration Days: The duration of standing orders in days.
- Standing Order Frequency Days: The frequency of standing orders in days.
- Standing Order Start Date: The start date for standing orders.
- Status: The status of the surgery document.
- Subject: The subject or title of the surgery document.
- Submitter: The entity or person who submitted the surgery document.
- Patient ID: A unique identifier for the patient.
- Specimen Draw Location: The location of specimen draw.
Surgery documents are crucial for documenting and managing surgical procedures, ensuring proper communication and coordination among healthcare providers and stakeholders.
Mapping Table
| Data Field | Example Value | Source Data Field Description | Source Field Data Type | Source Data Field Cardinality | Mapped FHIR++ Resource | Mapped FHIR Data Field | Augmented Mapping | Associated Coding System | Associated FHIR Data Field Extension | Mapping Context |
|---|---|---|---|---|---|---|---|---|---|---|
| actionnote | - | The most recent action note for a document | string | 0..1 | DocumentReference | extension.valueString | action-note | Top Level | ||
| alarmdays | - | The number days until a document will go into followup after being sent to the portal. | string | 0..1 | DocumentReference | extension.valueString | alarm-days | Top Level | ||
| appointmentid | - | The appointment ID for this document | integer | 0..1 | DocumentReference | extension.valueString | appointment-id | Top Level | ||
| approveddate | - | The date this document was approved | string | 0..1 | DocumentReference | extension.valueString | approved-date | Top Level | ||
| assignedto | - | Person the document is assigned to | string | 0..1 | DocumentReference | extension.valueString | assigned-to | Top Level | ||
| attachments.documentclass | - | Class of the attached document. | string | 0..1 | DocumentReference | contained.category.coding.code | Contained | |||
| attachments.documentdescription | - | A description of the attached document | string | 0..1 | DocumentReference | contained.description | Contained | |||
| attachments.documentid | - | ID of the attached document. | integer | 0..1 | DocumentReference | contained.id | Contained | |||
| attachments.encounterid | - | ID of the attached encounter or order group | integer | 0..1 | DocumentReference | contained.context.encounter.reference | Contained | |||
| attachments.flowsheetid | - | ID of the attached flowsheet | integer | 0..1 | DocumentReference | contained.extension.valueString | flow-sheet-id | Contained | ||
| attachments.sectionname | - | Section name for the attached document. | string | 0..1 | DocumentReference | contained.extension.valueString | section-name | Contained | ||
| attachments.sectionnamekey | - | Key name of the section of the attached document. | string | 0..1 | DocumentReference | contained.extension.valueString | section-name-key | Contained | ||
| cclist.address | - | The address of this clinical provider. | string | 0..1 | Location | contained.address.line[0] | Contained | |||
| cclist.city | - | The city of this clinical provider. | string | 0..1 | Location | contained.address.city | Contained | |||
| cclist.fax | - | The fax number of this clinical provider. | string | 0..1 | Location | contained.address | Contained | |||
| cclist.name | - | The name of this clinical provider. | string | 0..1 | Location | contained.name | Contained | |||
| cclist.phone | - | The phone number of this clinical provider. | string | 0..1 | Location | contained.telecom.value | system=phone | Contained | ||
| cclist.state | - | The state of this clinical provider. | string | 0..1 | Location | contained.address.state | Contained | |||
| cclist.zip | - | The zipcode of this clinical provider. | string | 0..1 | Location | contained.address.postalCode | Contained | |||
| clinicalproviderid | - | The ID of the clinical provider associated with this clinical document. Clinical providers are a master list of providers throughout the country. These include providers as well as radiology centers, labs and pharmacies. | integer | 0..1 | DocumentReference | custodian.reference.code | Top Level | |||
| clinicalprovidername | - | The Name of the clinical provider associated with this clinical document. Clinical providers are a master list of providers throughout the country. These include providers as well as radiology centers, labs and pharmacies. | string | 0..1 | DocumentReference | custodian.reference.display | Top Level | |||
| createddatetime | - | Date/Time (ISO 8601) the document was created | string | 0..1 | DocumentReference | date | Top Level | |||
| createduser | - | The user who created this document. | string | 0..1 | DocumentReference | extension.valueString | created-user | Top Level | ||
| dateofservice | - | Date of service for this order. | string | 0..1 | DocumentReference | extension.valueDate | date-of-service | Top Level | ||
| declinedreason.code | - | The code indicating why the order was not given. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.code | declined-reason | Top Level | ||
| declinedreason.description | - | The codeset that the code belongs to. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.display | ||||
| declinedreason.codeset | - | The plaintext description of the reason the order was not given. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.system | ||||
| declinedreasontext | - | The user-facing description of the reason the order was not given. | string | 0..1 | DocumentReference | extension.valueString | declined-reason-text | Top Level | ||
| deleteddatetime | - | Date/time (ISO 8601) the document was deleted | string | 0..1 | DocumentReference | extension.valueDateTime | deleted-datetime | Top Level | ||
| departmentid | - | Department for the document | string | 0..1 | DocumentReference | extension.valueString | department-id | Top Level | ||
| diagnosislist.diagnosiscode.code | - | Diagnoses for this document | string | 0..1 | serviceRequest | reasonCode.coding.code | Contained | |||
| diagnosislist.diagnosiscode.codeset | - | string | 0..1 | serviceRequest | reasonCode.coding.display | Contained | ||||
| diagnosislist.diagnosiscode.description | - | string | 0..1 | serviceRequest | reasonCode.coding.system | Contained | ||||
| diagnosislist.snomedicdcodes.code | - | Diagnoses for this document | string | 0..1 | serviceRequest | reasonCode.coding.code | Contained | |||
| diagnosislist.snomedicdcodes.codeset | - | string | 0..1 | serviceRequest | reasonCode.coding.display | Contained | ||||
| diagnosislist.snomedicdcodes.description | - | string | 0..1 | serviceRequest | reasonCode.coding.system | Contained | ||||
| diagnosislist.snomedicdcodes.unstrippeddiagnosiscode | - | string | 0..1 | serviceRequest | reasonCode.coding.extension.valueString | unstripped-diagnosis-code | Contained | |||
| documentdescription | - | Description of the document type | string | 0..1 | DocumentReference | category.coding.display | Top Level | |||
| documentroute | - | Explains method by which the document was entered into the athenaNet (INTERFACE (digital), FAX, etc.) | string | 0..1 | DocumentReference | extension.valueString | document-route | Top Level | ||
| documentsource | - | Explains where this document originated. | string | 0..1 | DocumentReference | extension.valueString | document-source | Top Level | ||
| documentsubclass | - | Specific type of document | string | 0..1 | DocumentReference | category.extension.valueString | document-subclass | Top Level | ||
| documenttype | - | The description for this document | string | 0..1 | DocumentReference | extension.valueString | document-type | Top Level | ||
| documenttypeid | - | The ID of the description for this document | integer | 0..1 | DocumentReference | extension.valueString | document-type-id | Top Level | ||
| encounterid | - | Encounter ID | string | 0..1 | DocumentReference | context.encounter.reference | Top Level | |||
| externalaccessionid | - | The external accession ID for this document. Format depends on the system the ID belongs to. | string | 0..1 | DocumentReference | extension.valueString | external-accession-id | Top Level | ||
| externalnote | - | External note for the patient. | string | 0..1 | DocumentReference | extension.valueString | external-note | Top Level | ||
| facilityid | - | The ID of the clinical provider associated with this clinical document. Clinical providers are a master list of providers throughout the country. These include providers as well as radiology centers, labs and pharmacies. | integer | 0..1 | DocumentReference | custodian.reference | Top Level | |||
| hassummarycare | - | If true, document has a summary care record. | string | 0..1 | DocumentReference | extension.valueString | has-summary-care | Top Level | ||
| insurances.additionalinformation | - | Additional information note. | string | 0..1 | Coverage | extension.valueString | additional-information | Contained | ||
| insurances.authorizationnumber | - | Authorization number. | string | 0..1 | Coverage | identifier.value | Contained | |||
| insurances.authorizationstatus | - | The authorization status for this insurance. | string | 0..1 | Coverage | extension.valueString | authorization-status | Contained | ||
| insurances.effectiveenddate | - | Effective end date. | string | 0..1 | Coverage | period | Contained | |||
| insurances.effectivestartdate | - | Effective start date. | string | 0..1 | Coverage | period | Contained | |||
| insurances.insurancepackageid | - | Insurance package id. | string | 0..1 | Coverage | identifier.value | Contained | |||
| insurances.memberid | - | Member id. | string | 0..1 | Coverage | extension.valueString | member-id | Contained | ||
| insurances.name | - | Name of the insurance. | string | 0..1 | Coverage | class.name | Contained | |||
| insurances.patientinsuranceid | - | Patient insurance id. | string | 0..1 | Coverage | contaned.id | Contained | |||
| insurances.sequence | - | Number indicating insurance sequence: 1 - Primary, 2 - Secondary, 3 - Tertiary, 4 - Quaternary. | integer | 0..1 | Coverage | extension.valueInteger | sequence | Contained | ||
| insurances.visitsapproved | - | The number of visits approved. | integer | 0..1 | Coverage | extension.valueString | visits-approved | Contained | ||
| internalaccessionid | - | The internal accession ID for this document. Format depends on the system the ID belongs to. | string | 0..1 | DocumentReference | extension.valueString | internal-accession-id | Top Level | ||
| internalnote | - | The 'Internal Note' attached to this document | string | 0..1 | DocumentReference | extension.valueString | internal-note | Top Level | ||
| lastmodifieddatetime | - | Date/time (ISO 8601) the document was last modified | string | 0..1 | DocumentReference | extension.valueDateTime | last-modified-datetime | Top Level | ||
| lastmodifieduser | - | The user who last modified this document. | string | 0..1 | DocumentReference | extension.valueString | last-modified-user | Top Level | ||
| observationdatetime | - | Date/time (ISO 8601) the observation was taken | string | 0..1 | DocumentReference | extension.valueDateTime | observation-datetime | Top Level | ||
| surgeryid | - | ID of a surgery document | Integer | 0..1 | DocumentReference | id | Top Level | |||
| ordertype | - | Order type group name | string | 0..1 | DocumentReference | extension.valueString | order-type | Top Level | ||
| outofnetworkreferralreasonid | - | ID of the out of network referral reason. | integer | 0..1 | DocumentReference | extension.valueString | out-of-network-referral-reason-id | Top Level | ||
| pages.contenttype | - | The content-type that will be returned by the page image call. | string | 0..1 | DocumentReference | content.attachment.contentType | Top Level | |||
| patientcaseid | - | The patient case id | string | 0..1 | DocumentReference | extension.valueString | patient-case-id | Top Level | ||
| performdate | - | Date the order was performed. | string | 0..1 | DocumentReference | extension.valueDate | perform-date | Top Level | ||
| placeofservice | - | CMS Place of Service name. | string | 0..1 | DocumentReference | context.facilityType.coding.display | Top Level | |||
| placeofserviceid | - | CMS Place of Service code. | string | 0..1 | DocumentReference | context.facilityType.coding.code | Top Level | |||
| preschedulingchecklist.notes | - | Checklist note. | string | 0..1 | Task | note.text | Contained | |||
| preschedulingchecklist.status | - | Checklist status: INCOMPLETE, COMPLETE, N/A | string | 0..1 | Task | status | Contained | |||
| preschedulingchecklist.task | - | Checklist task name | string | 0..1 | Task | description | Contained | |||
| priority | - | Document priority, when available. 1 is high, 2 is normal. Some labs use other numbers or characters that are lab-specific. | string | 0..1 | DocumentReference | extension.valueString | priority | Top Level | ||
| procedurecodes | - | CPT codes associated with this order. | string | 0..1 | serviceRequest | code.coding.code | Top Level | |||
| providerid | - | Provider ID for this document | integer | 0..1 | DocumentReference | author.reference | Top Level | |||
| questions.answer | - | BETA FIELD: The custom list of questions and answers associated with this order.This list will vary by practice. | string | 0..1 | QuestionnaireResponse | item.text | Contained | |||
| questions.question | - | BETA FIELD: The custom list of questions and answers associated with this order.This list will vary by practice. | string | 0..1 | QuestionnaireResponse | item.answer.valueString | Contained | |||
| receivernote | - | The external note sent to the receiving facility | string | 0..1 | DocumentReference | extension.valueString | receiver-note | Top Level | ||
| requestedvisits | - | The number of requested visits. | integer | 0..1 | DocumentReference | extension.valueInteger | requested-visits | Top Level | ||
| schedulewithin | - | Timerange in which to schedule a referral order | string | 0..1 | DocumentReference | extension.valueString | schedule-within | Top Level | ||
| specimencollectedby | - | The username of the individual who took the specimen | string | 0..1 | Specimen | collection.extension.valueString | specimen-collected-by | Contained | ||
| specimencollectiondatetime | - | Date/time (ISO 8601) of the specimen collection | string | 0..1 | Specimen | collection.collected.collectedDateTime | Contained | |||
| specimencollectionsite | - | Options are ExternalLab, Office, Home, AddOn | string | 0..1 | Specimen | collection.extension.valueString | specimen-collection-site | Contained | ||
| specimennotes | - | Note included with the specimen | string | 0..1 | Specimen | collection.note | Contained | |||
| specimensourceid | - | The internal ID of the site (on the patient) where the specimen was taken. Deprecated. Use SPECIMENSOURCENAME | integer | 0..1 | Specimen | collection.bodySite.coding.code | Contained | |||
| specimensourcename | - | The site (on the patient) where the specimen was taken | string | 0..1 | Specimen | collection.bodySite.coding.display | Contained | |||
| standingorderdurationdays | - | Duration of the standing order | integer | 0..1 | DocumentReference | extension.valueString | standing-order-duration-days | Top Level | ||
| standingorderfrequencydays | - | Frequency at which the order repeats | integer | 0..1 | DocumentReference | extension.valueString | standing-order-frequency-days | Top Level | ||
| standingorderstartdate | - | Start date of the standing order | string | 0..1 | DocumentReference | extension.valueString | standing-order-start-date | Top Level | ||
| status | - | Status of the document | string | 0..1 | DocumentReference | status | Top Level | |||
| subject | - | Subject of the document | string | 0..1 | DocumentReference | extension.valueString | subject | Top Level | ||
| submitter | - | Submitter of a document. | string | 0..1 | DocumentReference | extension.valueString | submitter | Top Level | ||
| summarycaredocumentid | - | ID of the summary care document. | integer | 0..1 | DocumentReference | extension.valueString | summary-care-document-id | Top Level | ||
| tiedtodocuments.documentclass | - | The document class. | string | 0..1 | DocumentReference | context.related.display | Top Level | |||
| tiedtodocuments.documentid | - | The document id. | integer | 0..1 | DocumentReference | context.related.reference | Top Level | |||
| tiedtodocuments.documentsubclass | - | The document subclass. | string | 0..1 | DocumentReference | context.related.extension | Top Level | |||
| tietoorderid | - | Order ID of the order this document is tied to, if any | integer | 0..1 | DocumentReference | context.related.reference | Top Level | |||
| documentclass | - | Class of document | string | 0..1 | DocumentReference | category.coding.code | Top Level | |||
| documentdate | - | Date/time the observation was taken | string | 0..1 | DocumentReference | extension.valueString | document-date | Top Level | ||
| patientid | - | The athenaNet patient ID. | integer | 0..1 | DocumentReference | subject.reference | Top Level | |||
| specimendrawlocation | - | Options are ExternalLab, Office, Home, AddOn | string | 0..1 | Specimen | extension.valueString | Contained |