Surgical Result Document
Source Object: Surgical Result Document
Overview: The "Surgical Result Document" source object contains data related to surgical results and documents generated during surgical procedures. This information is crucial for maintaining post-operative records, clinical decision-making, and communication among healthcare providers.
Key Data Fields:
- Appointment ID: Identifier for the associated surgical procedure.
- Clinical Provider ID: Unique identifier of the clinical provider.
- Contraindication Reason: Code and description for contraindication reasons.
- Created Date/Time: Timestamp of document creation.
- Declined Reason: Code, description, and text for declined reasons.
- Department ID: Identifier of the healthcare department.
- Document Type: Classification and description of the document.
- Encounter ID: Identifier for the healthcare encounter.
- Observation Date/Time: Timestamp associated with observations.
- Patient ID: Identifier of the patient.
- Status: Document status (e.g., pending, reviewed, finalized).
- Subject: Subject or topic of the surgical result document.
- Last Modified Date/Time: Timestamp of the last document modification.
Surgical result documents play a critical role in post-operative care and clinical decision-making, providing essential data for healthcare providers.
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 |
|---|---|---|---|---|---|---|---|---|---|---|
| appointmentid | - | The appointment ID for this document. | number | 0..1 | DocumentReference | context.related.reference | - | Top Level | ||
| assignedto | - | Person the document is assigned to | string | 0..1 | DocumentReference | extension.valueString | assigned-to | Top Level | ||
| clinicalproviderid | - | The clinical provider ID of the performing provider | number | 0..1 | DocumentReference | custodian.reference | Top Level | |||
| contraindicationreason.code | - | The code indicating why the order was contraindicated. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.code | contraindication-reason | Top Level | ||
| contraindicationreason.codeset | - | The codeset that the code belongs to. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.system | Top Level | |||
| contraindicationreason.description | - | The plaintext description of the contraindication reason. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.display | Top Level | |||
| createddatetime | - | Date/Time (ISO 8601) the document was created | string | 0..1 | DocumentReference | date | Top Level | |||
| declinedreason.code | - | The code indicating why the order was contraindicated. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.code | declined-reason | Top Level | ||
| declinedreason.codeset | - | The codeset that the code belongs to. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.system | Top Level | |||
| declinedreason.description | - | The plaintext description of the contraindication reason. | string | 0..1 | DocumentReference | extension.valueCodeableConcept.display | Top Level | |||
| 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 | ||
| documentclass | - | Class of document | string | 0..1 | DocumentReference | category.coding.code | Top Level | |||
| documentdescription | - | Description of the document type | string | 0..1 | DocumentReference | description | 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 (e.g. ENCOUNTER, PORTAL, etc.) | 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 | number | 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 | ||
| surgicalresultid | - | The primary key for surgicalresult class of documents | number | 0..1 | DocumentReference | id | Top Level | |||
| 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 | ||
| observationdatetime | - | Date/time (ISO 8601) the observation was taken | string | 0..1 | DocumentReference | extension.valueDateTime | observation-datetime | Top Level | ||
| patientid | - | The athenaNet patient ID | number | 0..1 | DocumentReference | subject.reference | Top Level | |||
| priority | - | Document priority, when available. | number | 0..1 | DocumentReference | extension.valueString | priority | Top Level | ||
| providerid | - | Provider ID for this document | number | 0..1 | DocumentReference | author.reference | Top Level | |||
| receivernote | - | External note sent to the receiving facility | string | 0..1 | DocumentReference | extension.valueString | receiver-note | 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 | ||
| tietoorderid | - | Order ID of the order this document is tied to, if any | number | 0..1 | DocumentReference | context.related.reference | Top Level |