Surgery
Class SurgeryPerformed

Surgical operation or procedure, especially one involving the removal or replacement of a diseased organ or tissue.

Attributes
«CS» Code abortedTimeframe abortedTimeframe

Categorizes when the surgical case was aborted as either: Pre-anesthesia; Post-anesthesia; not-aborted. Any medication or intervention, other than a peripheral IV, performed by anesthesia is considered post-anesthesia. This includes any anesthesia or intervention performed by anesthesia staff in the preoperative holding area. [FileMan 130,18.5].

String admissionStatus admissionStatus

Indicates the patient's acute hospital admission status on the calendar day of surgery. Possible values include: The operation was same day (the patient was not admitted); The patient was admitted on the calendar day of surgery; or The patient was already hospitalized on the calendar day prior to surgery. [FileMan 130,.011]

AnesthesiaEvent anesthesia anesthesia

The loss of sensation and usually of consciousness without loss of vital functions artificially produced by the administration of one or more agents that block the passage of pain impulses along nerve pathways to the brain Source: Merriam-Webster's Medical Dictionary, 2002 Merriam-Webster, Inc.

PractitionerParticipation assistantPerfusionist assistantPerfusionist

The person assisting the perfusionist. [FileMan 130,.168]. A perfusionist is a healthcare professional who uses the cardiopulmonary bypass machine (heart–lung machine) during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.

ServiceDeliveryLocation associatedClinic associatedClinic

Identifies the operating room where the principal operation is performed for this patient. [FileMan 130,.02]

PractitionerParticipation attendingSurgeon attendingSurgeon

The attending staff surgeon responsible for this case. The need for this information is made necessary when the surgeon performing the procedure is in a training status. [FileMan 130,.164]
Identifies the attending staff provider responsible for this case. This is required when the provider is in training status. [FileMan 130,124]

«PQ» Quantity bloodLoss bloodLoss

The amount of blood (in milliliters) estimated to be lost during the operative procedure (EBL). [Fileman 130,.25]

BodilyFluidAdministration bodyFluid bodyFluid

Pointer to replacement fluid given intravascularly during the operative procedure. [Fileman 130,.27].

String briefClinicalHistory briefClinicalHistory

A brief clinical history for this patient. It will appear on the Tissue Examination Report. [FileMan 130,60]

CardiacSurgeryEvaluation cardiacSurgeryEvaluation cardiacSurgeryEvaluation

Pointer to information collected to measure quality as defined by NSQIP/CICSP.

PractitionerParticipation catheterInsertedBy catheterInsertedBy

The person accountable for insertion of the Foley catheter. [FileMan 130,.57]

CellSaverEvent cellSaver cellSaver

Pointer to any cell savers used during this procedure. [Fileman 130.130].

PractitionerParticipation circSupport circSupport

Identifies the nurse with operating room circulating role responsibilities during the time of the surgery. [FileMan 130,.111]. A circulating nurse is a registered nurse who works in the operating room environment. The circulating nurse does not scrub in and performs job duties that cannot be done by staff that is scrubbed in and must remain sterile.

«CS» Code didPatientVoid didPatientVoid

Indicates whether the patient voided prior to being transported to the operating room. Possible values include: Yes; No; Inapplicable. [FileMan 130,.9813]

«CS» Code dischargedVia dischargedVia

Categorizes the mode of transport used to move the patient from the care area. [FileMan 130,25].

«CS» Code doNotResuscitateStatus doNotResuscitateStatus

If the patient has had a Do-Not-Resuscitate (DNR) order written in the physician's order sheet of the patient's chart and it has been signed or co-signed by an attending physician [this is the only condition under which a DNR order is official in the 30 days prior to this surgery], enter Yes. If the DNR order as defined above was rescinded immediately prior to surgery in order to operate on the patient, enter Yes. Answer No if DNR discussions are documented in the progress note, but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official order. Possible Values include: Yes; No; No study. [FileMan 130, 238]

«CS» Code dressingCondition dressingCondition

Categorizes the status of the drainage on the dressing. Possible values include: Dry; Serosanguinous; Sanguinous; No dressing. [FileMan 130,7]

String dressingsUsed dressingsUsed

The dressing(s) used for this case (free text). [FileMan 130,41]

«CS» Code electrodePosition electrodePosition

Categorizes the area of placement (body site) of the dispersive electrode pad. [FileMan 130,.55]
Categorizes the placement (body site) of the second dispersive electrode pad. [FileMan 130,6]

ElectrosurgicalUnit electrosurgicalUnit electrosurgicalUnit

Pointer to the electrosurgical unit utilized during the operative procedure. [FileMan 130,.75]

PrePostOpAssessment endAssessment endAssessment

Pointer to an assessment of the patient's vital signs upon completion of the operative procedure.

PractitionerParticipation finalCountsPerformer finalCountsPerformer

"This is the name of the person doing the final count of sponges, sharps and instruments." [FileMan 130,47]

«CS» Code finalCountsVerified finalCountsVerified

Categorizes the status of the final count of sponges, sharps, and instruments, etc. at the end of the surgical procedure. Possible values include: Correct; Incorrect; Unknown. [FileMan 130,.52]

PractitionerParticipation finalCountsVerifier finalCountsVerifier

The person responsible for verifying that the final sponge, sharps, and instrument counts are correct at the end of this operative procedure. [FileMan 130,.522]
Identifies the person responsible for verifying the final sponge, sharps and instrument counts. [FileMan 130,48]

PractitionerParticipation firstAssistant firstAssistant

The person assisting the surgeon during the major portion of the principal operation. [FileMan 130,.15]

«PQ» Quantity foleyCatheterSize foleyCatheterSize

The size of the Foley catheter. [FileMan 130,.56]

«REAL» Decimal gastricOutput gastricOutput

The gastric output, in cubic centimeters, during the operative procedure. [FileMan 130,62]

PractitionerParticipation hairRemovalSupport hairRemovalSupport

Identifies the person responsible for removing the patient's hair in preparation for the operative procedure (if necessary). [FileMan 130,.12]

PractitionerParticipation idConsentVerifiedBy idConsentVerifiedBy

The name of the person verifying the patient's identification band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent on the patient's record. [FileMan 130,.69]

Image image image

Pointers to images that are related to this case. [FileMan 130,2005]

«TS» PointInTime inductionCompleteTime inductionCompleteTime

The date and time that the anesthetist declares the patient ready for the start of the operative procedure. [FileMan 130,.215]

Occurrence intraOpOccurrence intraOpOccurrence

Pointer to information related to any intraoperative occurrences. [FileMan 130,1.14]

IrrigationEvent irrigation irrigation

Pointer to information related to the irrigation solution used. [Fileman 130,.39].

String isMajor isMajor

Categorizes the surgery case as major or minor. A Major case is any operation performed under general, spinal, or epidural anesthesia plus all inguinal herniorrhaphies, carotid endarterectomies, parathyroidectomies, thyroidectomies, breast lumpectomies, or endovascular abdominal aortic aneurysm (AAA) repairs regardless of anesthesia administered. All other operations are designated as Minor. [FileMan 130,.015]

Boolean isNonORSurgicalProcedure isNonORSurgicalProcedure

Indicates whether this case is a non-operating-room surgical procedure. [FileMan 130,118]

PractitionerParticipation ivStartedBy ivStartedBy

Identifies the person that started the IV for this operative procedure. [FileMan 130,63]

LabTestRequest labRequest labRequest

Laboratory tests ordered for this surgery case. Includes preoperative tests (e.g., anti-coagulation titers) and tests on specimens extracted from the patient during surgery (e.g., biopsy, cultures).

LaboratoryObservation labResults labResults

Results of laboratory tests ordered for this surgery case. Includes preoperative tests (e.g., anti-coagulation titers) and tests on specimens extracted from the patient during surgery (e.g., biopsy, cultures).

Laser laser laser

Pointer to any laser units used during this procedure. [FileMan 130,129]

«PQ» Quantity minimumTemperature minimumTemperature

The lowest temperature of the patient (in degrees Centigrade) during the operative procedure. [FileMan 130,.36]

Occurrence nonOperativeOccurrence nonOperativeOccurrence

Pointer to occurrences that are not related to a surgical procedure. [FileMan 130,53]

ServiceDeliveryLocation nonOrLocation nonOrLocation

Indicates the non-operating-room location where the surgical procedure was performed. [FileMan 130,119]

Occurrence nonOrOccurrence nonOrOccurrence

Pointer to an occurrence that is related to a non-O.R. procedure [FileMan 130,126]

«CS» Code opDisposition opDisposition

The destination of the patient upon transfer from OR staff care. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.46]

ServiceDeliveryLocation operatingRoom operatingRoom

Identifies the operating room where the principal operation is performed for this patient. [FileMan 130,.02]

«TS» PointInTime operationEndTime operationEndTime

The date and time that the operation ended. Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct; all postoperative radiological studies to be done in the OR/PR are completed; all dressings and drains are secured; and the physician/surgeons have completed all procedure-related activities on the patient. Should the patient expire in the operating room, this is the time that the patient was pronounced dead. [FileMan 130,.23]
The date and time that all the procedures for this non-OR case are complete. [FileMan 130,122]

«TS» PointInTime operationStartTime operationStartTime

The date and time that the operation began. The definition of this time is usually 'knife fall', but may vary depending on the type of surgery being performed. Non-Cardiac Definition Revised(2004): Procedure/Surgery Start Time (PST): Time the procedure is begun (e.g., incision for a surgical procedure). [FileMan 130,.22]
The date that the non-OR procedure was performed. [FileMan 130,120]
The time of the start of the non-OR procedure. [FileMan 130,121]

String operativeFindings operativeFindings

A brief description of the operative findings which appears on the Tissue Examination Report. [FileMan 130,59]

DeviceInstance otherDevice otherDevice

Devices used in this procedure that are not documented elsewhere. [Fileman 130.131].

PractitionerParticipation otherPersonsInOr otherPersonsInOr

Identifies other persons, not scrubbed or otherwise identified, present in the operating room. [FileMan 130,31]

Diagnosis otherPostOpDiagnosis otherPostOpDiagnosis

Any postoperative diagnosis in addition to the principal postoperative diagnosis. [FileMan 130,.74]

Diagnosis otherPreOpDiagnosis otherPreOpDiagnosis

Any diagnosis in addition to the principal preoperative diagnosis. [FileMan 130,.72]

OtherProcedure otherProcedure otherProcedure

Pointer to procedures performed in addition to the principal surgical procedure. [FileMan 130,.42]

PractitionerParticipation otherScrubbedPersonnel otherScrubbedPersonnel

Identifies other persons in the operating room in addition to those already listed as scrubbed. [FileMan 130,30]

«REAL» Decimal pacuAdmitScore pacuAdmitScore

The objective evaluation numerical score of the patient upon admission to the post anesthesia care unit. [FileMan 130,1.11]

«TS» PointInTime pacuAdmitTime pacuAdmitTime

The date/time that the patient was admitted to the post anesthesia care unit (recovery room). [FileMan 130,1.17]

«REAL» Decimal pacuDischargeScore pacuDischargeScore

The objective evaluation numeric score of the patient at discharge from the post anesthesia care unit. [FileMan 130,1.12]

«TS» PointInTime pacuDischargeTime pacuDischargeTime

The date/time that the patient is discharged from the post anesthesia care unit (recovery room).[FileMan 130,1.18]

«CS» Code pacuDisposition pacuDisposition

The destination of the patient immediately after release from the post-anesthesia care unit. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.79]

PractitionerParticipation perfusionist perfusionist

The person operating the cardio-pulmonary or organ perfusion apparatus. [FileMan 130,.167]. A perfusionist is a healthcare professional who uses the cardiopulmonary bypass machine (heart–lung machine) during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.

PhysiologicMonitoringEvent physiologicMonitoring physiologicMonitoring

Pointer to information related to invasive or non-invasive monitors used during this case. [FileMan 130,.293]

String plannedAdmissionStatus plannedAdmissionStatus

This field indicates the patient's planned hospital admission status for the calendar day of surgery. Possible values include: The operation is planned as same day (the patient will not be admitted); The patient will be admitted on the calendar day of surgery; or The patient will already be hospitalized on the calendar day prior to the date of surgery. [FileMan 130,.013]

«CS» Code plannedDisposition plannedDisposition

The location of care after the patient leaves the operating room and/or the post-anesthesia care unit. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.43]

PrePostOpAssessment postOpAssessment postOpAssessment

Pointer to an assessment of the patient's vital signs, skin integrity and color, mood, etc. immediately after the surgical procedure.

PostOpOccurrence postOpOccurrence postOpOccurrence

Pointer to information related to postoperative occurrences. [FileMan 130,1.16]

PrePostOpAssessment preOpAssessment preOpAssessment

Pointer to an assessment of the patient's vital signs, skin integrity and color, mood, etc. upon arrival to the operating room.

PractitionerParticipation primarySurgeon primarySurgeon

The person performing the major portion of the principal operative procedure. [FileMan 130,.14]

Diagnosis principalPostOpDiagnosis principalPostOpDiagnosis

The principal diagnosis for which the non-OR procedure is being performed (free text). [FileMan 130,33]
The principal postoperative diagnosis (coded). [FileMan 130,34]

Diagnosis principalPreOpDiagnosis principalPreOpDiagnosis

The preoperative diagnosis for which the surgical procedure is being performed (free text). [FileMan 130,32]
The principal Pre-OP ICD diagnosis code (coded). [FileMan 130,32.5]

ProsthesisInstalled prosthesisInstalled prosthesisInstalled

Pointer to information related to the prosthesis used for this operative procedure. [FileMan 130,.47]

RestraintOrPositionalAidApplied restraintOrPositionalAidApplied restraintOrPositionalAidApplied

Pointer to information related to restraints and positioning aids used during this operative procedure.. [FileMan 130,.13]

String scheduleType scheduleType

Categorizes how this surgery case was scheduled. This information is useful for prioritizing changes to the schedule. Possible values include: Emergency; Elective; Add-on (non-emergent); Stand-by, Urgent. Non-Cardiac Definition of Emergency Case (2004): An emergency case is usually performed as soon as possible and no later than 12 hours after the patient has been admitted to the hospital or after the onset of related preoperative symptomatology. [FileMan 130,.035]

PractitionerParticipation scrubSupport scrubSupport

Identifies the nurse with scrub role responsibilities during the time of the surgery. [FileMan 130,.112]. A Scrub nurse, also called a perioperative nurse, is a registered nurse who works directly with the surgeon within the sterile field by passing instruments, sponges, and other items needed during the surgical procedure.

PractitionerParticipation secondAssistant secondAssistant

The second person assisting the surgeon during the major portion of the principal operation. [FileMan 130,.16]

«CS» Code skinPrepAgent skinPrepAgent

The type of agent used to wash and prepare the operative site. [FileMan 130,.175]. Note that this might point to a MedicinalProduct in the future.

PractitionerParticipation skinPreppedBy skinPreppedBy

The person responsible for applying the agent used to wash and prepare the operative site. [FileMan 130,.18]
The second person performing skin preparation, if applicable. [FileMan 130,4]
The third person performing the preoperative skin preparation. [FileMan 130,5]

Specimen specimen specimen

Pointer to any specimen(s) collected and sent to the lab for analysis. [FileMan 130,49] (Note that in VistA, this is a string field, in FHIM is is a pointer to the Specimen class).

String surgeonSupervisoryLevel surgeonSupervisoryLevel

Categorizes the highest level of resident supervision provided by the attending staff surgeon for this case. [FileMan 130,.166]. Possible values include: Attending performed the operation; Attending in the operating room assisting the resident; Attending in the operating room but not scrubbed; Attending not present in the operating room suite but immediately available, etc.

SurgeryPosition surgeryPosition surgeryPosition

Pointer to the position in which the patient is placed for this operative procedure. [FileMan 130,64]

String surgerySpecialty surgerySpecialty

The surgical specialty assigned to the surgeon performing this operative procedure. Used for aggregating and reporting cases by specialty or department. [FileMan 130,.04]

ThermalUnitUtilization thermalUnitUtilization thermalUnitUtilization

Pointer to information related to the temperature controlling device. [FileMan 130,.757]

«TS» PointInTime timePatientLeftOR timePatientLeftOR

The date and time the patient was transported out of the operating room. If the patient dies prior to leaving the OR, then indicate the time of death for this data element. [FileMan 130,.232]

«TS» PointInTime timeTimeOutCompleted timeTimeOutCompleted

The actual time when the entire Time-Out process was completed by the OR team. [FileMan 130,74]

«PQ» Quantity totalUrineOutput totalUrineOutput

The amount of urine (in milliliters) output during the operative procedure. [Fileman 130,.255]

TourniquetApplied tourniquetApplied tourniquetApplied

Pointer to information related to the application of a tourniquet. [FileMan 130,.48]

«CS» Code transportMethod transportMethod

The method or device used to deliver the patient to the operating room. [FileMan 130,.11]

String tubesAndDrains tubesAndDrains

A textual description of the type and placement of tubes and drains during the operative process. [FileMan 130,22]

String verificationComments verificationComments

Provides additional explaination in those cases where the Time-Out Verified property is set to No. [FileMan 130,82]
Provides additional explaination in those cases where the Imaging Verified property is set to No. [FileMan 130,83]
Provides additional explaination in those cases where the Marked Site Verified property is set to No. [FileMan 130,84]

Boolean wasCaseVerified wasCaseVerified

Indicates whether the principal operative procedure, CPT code, perioperative occurrences and diagnosis were verified by the surgeon. [FileMan 130,43]

Boolean wasMarkedSiteVerified wasMarkedSiteVerified

Indicates whether a "Marked Site" confirmation process was completed prior to the start of the procedure. The site can and must be marked in almost all cases. Mucous membranes and other sites not on the skin cannot be marked using standard methods and do not need to be. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,73]

Boolean wasPreOpImagingConfirmed wasPreOpImagingConfirmed

Indicates whether a verification process was completed in which the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and verified by two members of the operating team prior to the start of the procedure. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,72]

Boolean wasSeqCompressDeviceUsed wasSeqCompressDeviceUsed

Indicates a whether sequential compression device was used. [FileMan 130,127]

Boolean wasTimeOutVerified wasTimeOutVerified

Indicates whether a "Time Out" verification process was conducted prior to the start of the procedure. A designated member of the OR team states the name of the patient, the procedure to be performed, the location of the site (including laterality if applicable), and the specifications of the implant to be used (if applicable). At a minimum, this process must include the surgeon the circulating nurse, and the anesthesia provider. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,71]

«CS» Code woundClassification woundClassification

Indicates whether the wound has been classified by the primary surgeon as:
Class 1 - Clean: Respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Uninfected surgical wounds. No inflammation is encountered. Closed primarily and, if necessary, drained with closed drainage. Surgical incisional wounds that occur with nonpenetrating (e.g., blunt) trauma should be included in this category if they meet the criteria. [No hollow organ (e.g. bladder, stomach, vagina, lung, etc.) is entered; no breaks in aseptic technique.]
Class 2 - Clean/Contaminated: Respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major breaks in technique are encountered. (Hollow organ entered but controlled; no inflammation; primary wound closure; minor break in aseptic technique; mechanical drain used.)
Class 3 - Contaminated: Open fresh, accidental (e.g. traumatic) wounds. Procedures that have major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.
Class 4 - Dirty/Infected: Old traumatic wounds that have retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the surgical field before the procedure. (Untreated, uncontrolled spillage from an internal organ; pus in operative wound; open suppurative wound; severe inflammation.)
[FileMan 130,1.09]

Attributes inherited from FHIM::Common::ActionPerformed FHIM::Common::ActionPerformed
basedOn basedOn, bodySite bodySite, complication complication, complicationDetail complicationDetail, duration duration, enactsPlan enactsPlan, focalDevice focalDevice, followUp followUp, fulfillsOrder fulfillsOrder, fulfillsPromise fulfillsPromise, nonCompletionTimeframe nonCompletionTimeframe, outcome outcome, partOf partOf, performancePeriod performancePeriod, performer performer, procedureModifier procedureModifier, report report, researchStudy researchStudy, status status, statusReason statusReason, timesPerformed timesPerformed, topicCode topicCode, usedCode usedCode, usedReference usedReference, wasCompleted wasCompleted

Attributes inherited from FHIM::Common::ActionStatement FHIM::Common::ActionStatement
category category, currentStatus currentStatus, description description, indication indication, inputFinding inputFinding, instantiatesCanonical instantiatesCanonical, instantiatesUri instantiatesUri, insurance insurance, intent intent, justification justification, location location, method method, outputFinding outputFinding, precondition precondition, reasonCode reasonCode, reasonNarrative reasonNarrative, reasonReference reasonReference, relevantHistory relevantHistory, scope scope, supportingInformation supportingInformation, usingDevice usingDevice, wasReported wasReported

Attributes inherited from FHIM::Common::ClinicalStatement FHIM::Common::ClinicalStatement
clinicalDataSource clinicalDataSource, contentVersion contentVersion, contextCode contextCode, encounter encounter, note note, recordStatus recordStatus, relatedClinicalInformation relatedClinicalInformation, sourceRecordType sourceRecordType, sourceSystem sourceSystem, subjectGroup subjectGroup, subjectOfInformation subjectOfInformation, subjectOfRecord subjectOfRecord, temporalContext temporalContext, topicCode topicCode, cosigned cosigned, recorded recorded, signed signed, verified verified

Attributes inherited from FHIM::Common::InformationEntry FHIM::Common::InformationEntry
identifier identifier

Properties:

Alias
Classifier Behavior
Is Abstractfalse
Is Activefalse
Is Leaffalse
KeywordsEntryPoint
NameSurgeryPerformed
Name Expression
NamespaceSurgery
Owned Template Signature
OwnerSurgery
Owning Template Parameter
PackageSurgery
Qualified NameFHIM::Surgery::SurgeryPerformed
Representation
Stereotype
Template Parameter
VisibilityPublic

Attribute Details

 abortedTimeframe
Public «CS» Code abortedTimeframe

Categorizes when the surgical case was aborted as either: Pre-anesthesia; Post-anesthesia; not-aborted. Any medication or intervention, other than a peripheral IV, performed by anesthesia is considered post-anesthesia. This includes any anesthesia or intervention performed by anesthesia staff in the preoperative holding area. [FileMan 130,18.5].

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameabortedTimeframe
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::abortedTimeframe
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 admissionStatus
Public String admissionStatus

Indicates the patient's acute hospital admission status on the calendar day of surgery. Possible values include: The operation was same day (the patient was not admitted); The patient was admitted on the calendar day of surgery; or The patient was already hospitalized on the calendar day prior to surgery. [FileMan 130,.011]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameadmissionStatus
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::admissionStatus
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 anesthesia
Public AnesthesiaEvent anesthesia

The loss of sensation and usually of consciousness without loss of vital functions artificially produced by the administration of one or more agents that block the passage of pain impulses along nerve pathways to the brain Source: Merriam-Webster's Medical Dictionary, 2002 Merriam-Webster, Inc.

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_anesthesia
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower1
Lower Value(1)
Multiplicity1..*
Nameanesthesia
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::anesthesia
Stereotype
Template Parameter
TypeAnesthesiaEvent
Upper*
Upper Value(*)
VisibilityPublic


 assistantPerfusionist
Public PractitionerParticipation assistantPerfusionist

The person assisting the perfusionist. [FileMan 130,.168]. A perfusionist is a healthcare professional who uses the cardiopulmonary bypass machine (heart–lung machine) during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameassistantPerfusionist
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::assistantPerfusionist
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 associatedClinic
Public ServiceDeliveryLocation associatedClinic

Identifies the operating room where the principal operation is performed for this patient. [FileMan 130,.02]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameassociatedClinic
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::associatedClinic
Stereotype
Template Parameter
TypeServiceDeliveryLocation
Upper1
Upper Value(1)
VisibilityPublic


 attendingSurgeon
Public PractitionerParticipation attendingSurgeon

The attending staff surgeon responsible for this case. The need for this information is made necessary when the surgeon performing the procedure is in a training status. [FileMan 130,.164]
Identifies the attending staff provider responsible for this case. This is required when the provider is in training status. [FileMan 130,124]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameattendingSurgeon
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::attendingSurgeon
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 bloodLoss
Public «PQ» Quantity bloodLoss

The amount of blood (in milliliters) estimated to be lost during the operative procedure (EBL). [Fileman 130,.25]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamebloodLoss
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::bloodLoss
Stereotype
Template Parameter
Type«PQ» Quantity
Upper1
Upper Value(1)
VisibilityPublic


 bodyFluid
Public BodilyFluidAdministration bodyFluid

Pointer to replacement fluid given intravascularly during the operative procedure. [Fileman 130,.27].

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_bodyFluid
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamebodyFluid
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::bodyFluid
Stereotype
Template Parameter
TypeBodilyFluidAdministration
Upper*
Upper Value(*)
VisibilityPublic


 briefClinicalHistory
Public String briefClinicalHistory

A brief clinical history for this patient. It will appear on the Tissue Examination Report. [FileMan 130,60]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamebriefClinicalHistory
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::briefClinicalHistory
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 cardiacSurgeryEvaluation
Public CardiacSurgeryEvaluation cardiacSurgeryEvaluation

Pointer to information collected to measure quality as defined by NSQIP/CICSP.

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_cardiacSurgeryEvaluation
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamecardiacSurgeryEvaluation
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::cardiacSurgeryEvaluation
Stereotype
Template Parameter
TypeCardiacSurgeryEvaluation
Upper1
Upper Value(1)
VisibilityPublic


 catheterInsertedBy
Public PractitionerParticipation catheterInsertedBy

The person accountable for insertion of the Foley catheter. [FileMan 130,.57]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamecatheterInsertedBy
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::catheterInsertedBy
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 cellSaver
Public CellSaverEvent cellSaver

Pointer to any cell savers used during this procedure. [Fileman 130.130].

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_cellSaver
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower1
Lower Value(1)
Multiplicity1..*
NamecellSaver
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::cellSaver
Stereotype
Template Parameter
TypeCellSaverEvent
Upper*
Upper Value(*)
VisibilityPublic


 circSupport
Public PractitionerParticipation circSupport

Identifies the nurse with operating room circulating role responsibilities during the time of the surgery. [FileMan 130,.111]. A circulating nurse is a registered nurse who works in the operating room environment. The circulating nurse does not scrub in and performs job duties that cannot be done by staff that is scrubbed in and must remain sterile.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamecircSupport
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::circSupport
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 didPatientVoid
Public «CS» Code didPatientVoid

Indicates whether the patient voided prior to being transported to the operating room. Possible values include: Yes; No; Inapplicable. [FileMan 130,.9813]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedidPatientVoid
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::didPatientVoid
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 dischargedVia
Public «CS» Code dischargedVia

Categorizes the mode of transport used to move the patient from the care area. [FileMan 130,25].

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedischargedVia
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::dischargedVia
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 doNotResuscitateStatus
Public «CS» Code doNotResuscitateStatus

If the patient has had a Do-Not-Resuscitate (DNR) order written in the physician's order sheet of the patient's chart and it has been signed or co-signed by an attending physician [this is the only condition under which a DNR order is official in the 30 days prior to this surgery], enter Yes. If the DNR order as defined above was rescinded immediately prior to surgery in order to operate on the patient, enter Yes. Answer No if DNR discussions are documented in the progress note, but no official DNR order has been written in the physician order sheet or if the attending physician has not signed the official order. Possible Values include: Yes; No; No study. [FileMan 130, 238]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedoNotResuscitateStatus
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::doNotResuscitateStatus
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 dressingCondition
Public «CS» Code dressingCondition

Categorizes the status of the drainage on the dressing. Possible values include: Dry; Serosanguinous; Sanguinous; No dressing. [FileMan 130,7]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedressingCondition
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::dressingCondition
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 dressingsUsed
Public String dressingsUsed

The dressing(s) used for this case (free text). [FileMan 130,41]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedressingsUsed
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::dressingsUsed
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 electrodePosition
Public «CS» Code electrodePosition

Categorizes the area of placement (body site) of the dispersive electrode pad. [FileMan 130,.55]
Categorizes the placement (body site) of the second dispersive electrode pad. [FileMan 130,6]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..2
NameelectrodePosition
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::electrodePosition
Stereotype
Template Parameter
Type«CS» Code
Upper2
Upper Value(2)
VisibilityPublic


 electrosurgicalUnit
Public ElectrosurgicalUnit electrosurgicalUnit

Pointer to the electrosurgical unit utilized during the operative procedure. [FileMan 130,.75]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_electrosurgicalUnit
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameelectrosurgicalUnit
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::electrosurgicalUnit
Stereotype
Template Parameter
TypeElectrosurgicalUnit
Upper*
Upper Value(*)
VisibilityPublic


 endAssessment
Public PrePostOpAssessment endAssessment

Pointer to an assessment of the patient's vital signs upon completion of the operative procedure.

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_endAssessment
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameendAssessment
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::endAssessment
Stereotype
Template Parameter
TypePrePostOpAssessment
Upper1
Upper Value(1)
VisibilityPublic


 finalCountsPerformer
Public PractitionerParticipation finalCountsPerformer

"This is the name of the person doing the final count of sponges, sharps and instruments." [FileMan 130,47]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamefinalCountsPerformer
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::finalCountsPerformer
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 finalCountsVerified
Public «CS» Code finalCountsVerified

Categorizes the status of the final count of sponges, sharps, and instruments, etc. at the end of the surgical procedure. Possible values include: Correct; Incorrect; Unknown. [FileMan 130,.52]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamefinalCountsVerified
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::finalCountsVerified
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 finalCountsVerifier
Public PractitionerParticipation finalCountsVerifier

The person responsible for verifying that the final sponge, sharps, and instrument counts are correct at the end of this operative procedure. [FileMan 130,.522]
Identifies the person responsible for verifying the final sponge, sharps and instrument counts. [FileMan 130,48]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamefinalCountsVerifier
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::finalCountsVerifier
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 firstAssistant
Public PractitionerParticipation firstAssistant

The person assisting the surgeon during the major portion of the principal operation. [FileMan 130,.15]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamefirstAssistant
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::firstAssistant
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 foleyCatheterSize
Public «PQ» Quantity foleyCatheterSize

The size of the Foley catheter. [FileMan 130,.56]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamefoleyCatheterSize
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::foleyCatheterSize
Stereotype
Template Parameter
Type«PQ» Quantity
Upper1
Upper Value(1)
VisibilityPublic


 gastricOutput
Public «REAL» Decimal gastricOutput

The gastric output, in cubic centimeters, during the operative procedure. [FileMan 130,62]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamegastricOutput
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::gastricOutput
Stereotype
Template Parameter
Type«REAL» Decimal
Upper1
Upper Value(1)
VisibilityPublic


 hairRemovalSupport
Public PractitionerParticipation hairRemovalSupport

Identifies the person responsible for removing the patient's hair in preparation for the operative procedure (if necessary). [FileMan 130,.12]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamehairRemovalSupport
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::hairRemovalSupport
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 idConsentVerifiedBy
Public PractitionerParticipation idConsentVerifiedBy

The name of the person verifying the patient's identification band, Social Security Number, surgical site/procedure, and the entry of a valid operative consent on the patient's record. [FileMan 130,.69]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameidConsentVerifiedBy
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::idConsentVerifiedBy
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 image
Public Image image

Pointers to images that are related to this case. [FileMan 130,2005]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameimage
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::image
Stereotype
Template Parameter
TypeImage
Upper1
Upper Value(1)
VisibilityPublic


 inductionCompleteTime
Public «TS» PointInTime inductionCompleteTime

The date and time that the anesthetist declares the patient ready for the start of the operative procedure. [FileMan 130,.215]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
NameinductionCompleteTime
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::inductionCompleteTime
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 intraOpOccurrence
Public Occurrence intraOpOccurrence

Pointer to information related to any intraoperative occurrences. [FileMan 130,1.14]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_intraOpOccurrence
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameintraOpOccurrence
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::intraOpOccurrence
Stereotype
Template Parameter
TypeOccurrence
Upper*
Upper Value(*)
VisibilityPublic


 irrigation
Public IrrigationEvent irrigation

Pointer to information related to the irrigation solution used. [Fileman 130,.39].

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_irrigation
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
Nameirrigation
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::irrigation
Stereotype
Template Parameter
TypeIrrigationEvent
Upper*
Upper Value(*)
VisibilityPublic


 isMajor
Public String isMajor

Categorizes the surgery case as major or minor. A Major case is any operation performed under general, spinal, or epidural anesthesia plus all inguinal herniorrhaphies, carotid endarterectomies, parathyroidectomies, thyroidectomies, breast lumpectomies, or endovascular abdominal aortic aneurysm (AAA) repairs regardless of anesthesia administered. All other operations are designated as Minor. [FileMan 130,.015]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameisMajor
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::isMajor
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 isNonORSurgicalProcedure
Public Boolean isNonORSurgicalProcedure

Indicates whether this case is a non-operating-room surgical procedure. [FileMan 130,118]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameisNonORSurgicalProcedure
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::isNonORSurgicalProcedure
Stereotype
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 ivStartedBy
Public PractitionerParticipation ivStartedBy

Identifies the person that started the IV for this operative procedure. [FileMan 130,63]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameivStartedBy
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::ivStartedBy
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 labRequest
Public LabTestRequest labRequest

Laboratory tests ordered for this surgery case. Includes preoperative tests (e.g., anti-coagulation titers) and tests on specimens extracted from the patient during surgery (e.g., biopsy, cultures).

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_labRequest
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamelabRequest
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::labRequest
Stereotype
Template Parameter
TypeLabTestRequest
Upper*
Upper Value(*)
VisibilityPublic


 labResults
Public LaboratoryObservation labResults

Results of laboratory tests ordered for this surgery case. Includes preoperative tests (e.g., anti-coagulation titers) and tests on specimens extracted from the patient during surgery (e.g., biopsy, cultures).

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_labResults
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamelabResults
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::labResults
Stereotype
Template Parameter
TypeLaboratoryObservation
Upper*
Upper Value(*)
VisibilityPublic


 laser
Public Laser laser

Pointer to any laser units used during this procedure. [FileMan 130,129]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_laser
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
Namelaser
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::laser
Stereotype
Template Parameter
TypeLaser
Upper*
Upper Value(*)
VisibilityPublic


 minimumTemperature
Public «PQ» Quantity minimumTemperature

The lowest temperature of the patient (in degrees Centigrade) during the operative procedure. [FileMan 130,.36]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
NameminimumTemperature
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::minimumTemperature
Stereotype
Template Parameter
Type«PQ» Quantity
Upper1
Upper Value(1)
VisibilityPublic


 nonOperativeOccurrence
Public Occurrence nonOperativeOccurrence

Pointer to occurrences that are not related to a surgical procedure. [FileMan 130,53]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_nonOperativeOccurrence
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamenonOperativeOccurrence
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::nonOperativeOccurrence
Stereotype
Template Parameter
TypeOccurrence
Upper*
Upper Value(*)
VisibilityPublic


 nonOrLocation
Public ServiceDeliveryLocation nonOrLocation

Indicates the non-operating-room location where the surgical procedure was performed. [FileMan 130,119]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamenonOrLocation
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::nonOrLocation
Stereotype
Template Parameter
TypeServiceDeliveryLocation
Upper1
Upper Value(1)
VisibilityPublic


 nonOrOccurrence
Public Occurrence nonOrOccurrence

Pointer to an occurrence that is related to a non-O.R. procedure [FileMan 130,126]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_nonOrOccurrence
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamenonOrOccurrence
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::nonOrOccurrence
Stereotype
Template Parameter
TypeOccurrence
Upper*
Upper Value(*)
VisibilityPublic


 opDisposition
Public «CS» Code opDisposition

The destination of the patient upon transfer from OR staff care. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.46]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameopDisposition
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::opDisposition
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 operatingRoom
Public ServiceDeliveryLocation operatingRoom

Identifies the operating room where the principal operation is performed for this patient. [FileMan 130,.02]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameoperatingRoom
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::operatingRoom
Stereotype
Template Parameter
TypeServiceDeliveryLocation
Upper1
Upper Value(1)
VisibilityPublic


 operationEndTime
Public «TS» PointInTime operationEndTime

The date and time that the operation ended. Procedure/Surgery Finish (PF): Time when all instrument and sponge counts are completed and verified as correct; all postoperative radiological studies to be done in the OR/PR are completed; all dressings and drains are secured; and the physician/surgeons have completed all procedure-related activities on the patient. Should the patient expire in the operating room, this is the time that the patient was pronounced dead. [FileMan 130,.23]
The date and time that all the procedures for this non-OR case are complete. [FileMan 130,122]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameoperationEndTime
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::operationEndTime
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 operationStartTime
Public «TS» PointInTime operationStartTime

The date and time that the operation began. The definition of this time is usually 'knife fall', but may vary depending on the type of surgery being performed. Non-Cardiac Definition Revised(2004): Procedure/Surgery Start Time (PST): Time the procedure is begun (e.g., incision for a surgical procedure). [FileMan 130,.22]
The date that the non-OR procedure was performed. [FileMan 130,120]
The time of the start of the non-OR procedure. [FileMan 130,121]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameoperationStartTime
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::operationStartTime
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 operativeFindings
Public String operativeFindings

A brief description of the operative findings which appears on the Tissue Examination Report. [FileMan 130,59]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameoperativeFindings
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::operativeFindings
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 otherDevice
Public DeviceInstance otherDevice

Devices used in this procedure that are not documented elsewhere. [Fileman 130.131].

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_otherDevice
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameotherDevice
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::otherDevice
Stereotype
Template Parameter
TypeDeviceInstance
Upper*
Upper Value(*)
VisibilityPublic


 otherPersonsInOr
Public PractitionerParticipation otherPersonsInOr

Identifies other persons, not scrubbed or otherwise identified, present in the operating room. [FileMan 130,31]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameotherPersonsInOr
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::otherPersonsInOr
Stereotype
Template Parameter
TypePractitionerParticipation
Upper*
Upper Value(*)
VisibilityPublic


 otherPostOpDiagnosis
Public Diagnosis otherPostOpDiagnosis

Any postoperative diagnosis in addition to the principal postoperative diagnosis. [FileMan 130,.74]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameotherPostOpDiagnosis
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::otherPostOpDiagnosis
Stereotype
Template Parameter
TypeDiagnosis
Upper*
Upper Value(*)
VisibilityPublic


 otherPreOpDiagnosis
Public Diagnosis otherPreOpDiagnosis

Any diagnosis in addition to the principal preoperative diagnosis. [FileMan 130,.72]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameotherPreOpDiagnosis
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::otherPreOpDiagnosis
Stereotype
Template Parameter
TypeDiagnosis
Upper*
Upper Value(*)
VisibilityPublic


 otherProcedure
Public OtherProcedure otherProcedure

Pointer to procedures performed in addition to the principal surgical procedure. [FileMan 130,.42]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_otherProcedure
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameotherProcedure
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::otherProcedure
Stereotype
Template Parameter
TypeOtherProcedure
Upper*
Upper Value(*)
VisibilityPublic


 otherScrubbedPersonnel
Public PractitionerParticipation otherScrubbedPersonnel

Identifies other persons in the operating room in addition to those already listed as scrubbed. [FileMan 130,30]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameotherScrubbedPersonnel
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::otherScrubbedPersonnel
Stereotype
Template Parameter
TypePractitionerParticipation
Upper*
Upper Value(*)
VisibilityPublic


 pacuAdmitScore
Public «REAL» Decimal pacuAdmitScore

The objective evaluation numerical score of the patient upon admission to the post anesthesia care unit. [FileMan 130,1.11]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepacuAdmitScore
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::pacuAdmitScore
Stereotype
Template Parameter
Type«REAL» Decimal
Upper1
Upper Value(1)
VisibilityPublic


 pacuAdmitTime
Public «TS» PointInTime pacuAdmitTime

The date/time that the patient was admitted to the post anesthesia care unit (recovery room). [FileMan 130,1.17]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepacuAdmitTime
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::pacuAdmitTime
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 pacuDischargeScore
Public «REAL» Decimal pacuDischargeScore

The objective evaluation numeric score of the patient at discharge from the post anesthesia care unit. [FileMan 130,1.12]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepacuDischargeScore
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::pacuDischargeScore
Stereotype
Template Parameter
Type«REAL» Decimal
Upper1
Upper Value(1)
VisibilityPublic


 pacuDischargeTime
Public «TS» PointInTime pacuDischargeTime

The date/time that the patient is discharged from the post anesthesia care unit (recovery room).[FileMan 130,1.18]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepacuDischargeTime
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::pacuDischargeTime
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 pacuDisposition
Public «CS» Code pacuDisposition

The destination of the patient immediately after release from the post-anesthesia care unit. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.79]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepacuDisposition
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::pacuDisposition
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 perfusionist
Public PractitionerParticipation perfusionist

The person operating the cardio-pulmonary or organ perfusion apparatus. [FileMan 130,.167]. A perfusionist is a healthcare professional who uses the cardiopulmonary bypass machine (heart–lung machine) during cardiac surgery and other surgeries that require cardiopulmonary bypass to manage the patient's physiological status.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameperfusionist
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::perfusionist
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 physiologicMonitoring
Public PhysiologicMonitoringEvent physiologicMonitoring

Pointer to information related to invasive or non-invasive monitors used during this case. [FileMan 130,.293]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_physiologicMonitoring
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamephysiologicMonitoring
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::physiologicMonitoring
Stereotype
Template Parameter
TypePhysiologicMonitoringEvent
Upper*
Upper Value(*)
VisibilityPublic


 plannedAdmissionStatus
Public String plannedAdmissionStatus

This field indicates the patient's planned hospital admission status for the calendar day of surgery. Possible values include: The operation is planned as same day (the patient will not be admitted); The patient will be admitted on the calendar day of surgery; or The patient will already be hospitalized on the calendar day prior to the date of surgery. [FileMan 130,.013]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameplannedAdmissionStatus
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::plannedAdmissionStatus
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 plannedDisposition
Public «CS» Code plannedDisposition

The location of care after the patient leaves the operating room and/or the post-anesthesia care unit. Possible values include: Post-anesthesia care unit (PACU); Surgical intensive care unit (SICU); Inpatient; etc. [FileMan 130,.43]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameplannedDisposition
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::plannedDisposition
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 postOpAssessment
Public PrePostOpAssessment postOpAssessment

Pointer to an assessment of the patient's vital signs, skin integrity and color, mood, etc. immediately after the surgical procedure.

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_postOpAssessment
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepostOpAssessment
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::postOpAssessment
Stereotype
Template Parameter
TypePrePostOpAssessment
Upper1
Upper Value(1)
VisibilityPublic


 postOpOccurrence
Public PostOpOccurrence postOpOccurrence

Pointer to information related to postoperative occurrences. [FileMan 130,1.16]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_postOpOccurrence
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamepostOpOccurrence
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::postOpOccurrence
Stereotype
Template Parameter
TypePostOpOccurrence
Upper*
Upper Value(*)
VisibilityPublic


 preOpAssessment
Public PrePostOpAssessment preOpAssessment

Pointer to an assessment of the patient's vital signs, skin integrity and color, mood, etc. upon arrival to the operating room.

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_preOpAssessment
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamepreOpAssessment
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::preOpAssessment
Stereotype
Template Parameter
TypePrePostOpAssessment
Upper1
Upper Value(1)
VisibilityPublic


 primarySurgeon
Public PractitionerParticipation primarySurgeon

The person performing the major portion of the principal operative procedure. [FileMan 130,.14]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameprimarySurgeon
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::primarySurgeon
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 principalPostOpDiagnosis
Public Diagnosis principalPostOpDiagnosis

The principal diagnosis for which the non-OR procedure is being performed (free text). [FileMan 130,33]
The principal postoperative diagnosis (coded). [FileMan 130,34]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameprincipalPostOpDiagnosis
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::principalPostOpDiagnosis
Stereotype
Template Parameter
TypeDiagnosis
Upper1
Upper Value(1)
VisibilityPublic


 principalPreOpDiagnosis
Public Diagnosis principalPreOpDiagnosis

The preoperative diagnosis for which the surgical procedure is being performed (free text). [FileMan 130,32]
The principal Pre-OP ICD diagnosis code (coded). [FileMan 130,32.5]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameprincipalPreOpDiagnosis
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::principalPreOpDiagnosis
Stereotype
Template Parameter
TypeDiagnosis
Upper1
Upper Value(1)
VisibilityPublic


 prosthesisInstalled
Public ProsthesisInstalled prosthesisInstalled

Pointer to information related to the prosthesis used for this operative procedure. [FileMan 130,.47]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_prosthesisInstalled
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NameprosthesisInstalled
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::prosthesisInstalled
Stereotype
Template Parameter
TypeProsthesisInstalled
Upper*
Upper Value(*)
VisibilityPublic


 restraintOrPositionalAidApplied
Public RestraintOrPositionalAidApplied restraintOrPositionalAidApplied

Pointer to information related to restraints and positioning aids used during this operative procedure.. [FileMan 130,.13]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_restraintOrPositionalAidApplied
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamerestraintOrPositionalAidApplied
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::restraintOrPositionalAidApplied
Stereotype
Template Parameter
TypeRestraintOrPositionalAidApplied
Upper*
Upper Value(*)
VisibilityPublic


 scheduleType
Public String scheduleType

Categorizes how this surgery case was scheduled. This information is useful for prioritizing changes to the schedule. Possible values include: Emergency; Elective; Add-on (non-emergent); Stand-by, Urgent. Non-Cardiac Definition of Emergency Case (2004): An emergency case is usually performed as soon as possible and no later than 12 hours after the patient has been admitted to the hospital or after the onset of related preoperative symptomatology. [FileMan 130,.035]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamescheduleType
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::scheduleType
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 scrubSupport
Public PractitionerParticipation scrubSupport

Identifies the nurse with scrub role responsibilities during the time of the surgery. [FileMan 130,.112]. A Scrub nurse, also called a perioperative nurse, is a registered nurse who works directly with the surgeon within the sterile field by passing instruments, sponges, and other items needed during the surgical procedure.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamescrubSupport
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::scrubSupport
Stereotype
Template Parameter
TypePractitionerParticipation
Upper*
Upper Value(*)
VisibilityPublic


 secondAssistant
Public PractitionerParticipation secondAssistant

The second person assisting the surgeon during the major portion of the principal operation. [FileMan 130,.16]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamesecondAssistant
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::secondAssistant
Stereotype
Template Parameter
TypePractitionerParticipation
Upper1
Upper Value(1)
VisibilityPublic


 skinPrepAgent
Public «CS» Code skinPrepAgent

The type of agent used to wash and prepare the operative site. [FileMan 130,.175]. Note that this might point to a MedicinalProduct in the future.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameskinPrepAgent
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::skinPrepAgent
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 skinPreppedBy
Public PractitionerParticipation skinPreppedBy

The person responsible for applying the agent used to wash and prepare the operative site. [FileMan 130,.18]
The second person performing skin preparation, if applicable. [FileMan 130,4]
The third person performing the preoperative skin preparation. [FileMan 130,5]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..3
NameskinPreppedBy
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::skinPreppedBy
Stereotype
Template Parameter
TypePractitionerParticipation
Upper3
Upper Value(3)
VisibilityPublic


 specimen
Public Specimen specimen

Pointer to any specimen(s) collected and sent to the lab for analysis. [FileMan 130,49] (Note that in VistA, this is a string field, in FHIM is is a pointer to the Specimen class).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
Namespecimen
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::specimen
Stereotype
Template Parameter
TypeSpecimen
Upper*
Upper Value(*)
VisibilityPublic


 surgeonSupervisoryLevel
Public String surgeonSupervisoryLevel

Categorizes the highest level of resident supervision provided by the attending staff surgeon for this case. [FileMan 130,.166]. Possible values include: Attending performed the operation; Attending in the operating room assisting the resident; Attending in the operating room but not scrubbed; Attending not present in the operating room suite but immediately available, etc.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamesurgeonSupervisoryLevel
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::surgeonSupervisoryLevel
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 surgeryPosition
Public SurgeryPosition surgeryPosition

Pointer to the position in which the patient is placed for this operative procedure. [FileMan 130,64]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_surgeryPosition
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamesurgeryPosition
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::surgeryPosition
Stereotype
Template Parameter
TypeSurgeryPosition
Upper*
Upper Value(*)
VisibilityPublic


 surgerySpecialty
Public String surgerySpecialty

The surgical specialty assigned to the surgeon performing this operative procedure. Used for aggregating and reporting cases by specialty or department. [FileMan 130,.04]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamesurgerySpecialty
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::surgerySpecialty
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 thermalUnitUtilization
Public ThermalUnitUtilization thermalUnitUtilization

Pointer to information related to the temperature controlling device. [FileMan 130,.757]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_thermalUnitUtilization
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamethermalUnitUtilization
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::thermalUnitUtilization
Stereotype
Template Parameter
TypeThermalUnitUtilization
Upper*
Upper Value(*)
VisibilityPublic


 timePatientLeftOR
Public «TS» PointInTime timePatientLeftOR

The date and time the patient was transported out of the operating room. If the patient dies prior to leaving the OR, then indicate the time of death for this data element. [FileMan 130,.232]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NametimePatientLeftOR
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::timePatientLeftOR
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 timeTimeOutCompleted
Public «TS» PointInTime timeTimeOutCompleted

The actual time when the entire Time-Out process was completed by the OR team. [FileMan 130,74]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NametimeTimeOutCompleted
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::timeTimeOutCompleted
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 totalUrineOutput
Public «PQ» Quantity totalUrineOutput

The amount of urine (in milliliters) output during the operative procedure. [Fileman 130,.255]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NametotalUrineOutput
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::totalUrineOutput
Stereotype
Template Parameter
Type«PQ» Quantity
Upper1
Upper Value(1)
VisibilityPublic


 tourniquetApplied
Public TourniquetApplied tourniquetApplied

Pointer to information related to the application of a tourniquet. [FileMan 130,.48]

Constraints:
Properties:

AggregationNone
Alias
AssociationsurgeryPerformed_tourniquetApplied
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
NametourniquetApplied
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::tourniquetApplied
Stereotype
Template Parameter
TypeTourniquetApplied
Upper*
Upper Value(*)
VisibilityPublic


 transportMethod
Public «CS» Code transportMethod

The method or device used to deliver the patient to the operating room. [FileMan 130,.11]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NametransportMethod
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::transportMethod
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 tubesAndDrains
Public String tubesAndDrains

A textual description of the type and placement of tubes and drains during the operative process. [FileMan 130,22]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NametubesAndDrains
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::tubesAndDrains
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 verificationComments
Public String verificationComments

Provides additional explaination in those cases where the Time-Out Verified property is set to No. [FileMan 130,82]
Provides additional explaination in those cases where the Imaging Verified property is set to No. [FileMan 130,83]
Provides additional explaination in those cases where the Marked Site Verified property is set to No. [FileMan 130,84]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameverificationComments
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::verificationComments
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 wasCaseVerified
Public Boolean wasCaseVerified

Indicates whether the principal operative procedure, CPT code, perioperative occurrences and diagnosis were verified by the surgeon. [FileMan 130,43]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamewasCaseVerified
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::wasCaseVerified
Stereotype
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 wasMarkedSiteVerified
Public Boolean wasMarkedSiteVerified

Indicates whether a "Marked Site" confirmation process was completed prior to the start of the procedure. The site can and must be marked in almost all cases. Mucous membranes and other sites not on the skin cannot be marked using standard methods and do not need to be. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,73]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamewasMarkedSiteVerified
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::wasMarkedSiteVerified
Stereotype
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 wasPreOpImagingConfirmed
Public Boolean wasPreOpImagingConfirmed

Indicates whether a verification process was completed in which the presence of relevant imaging data to confirm the operative site for the correct patient are available, properly labeled and properly presented, and verified by two members of the operating team prior to the start of the procedure. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,72]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamewasPreOpImagingConfirmed
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::wasPreOpImagingConfirmed
Stereotype
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 wasSeqCompressDeviceUsed
Public Boolean wasSeqCompressDeviceUsed

Indicates a whether sequential compression device was used. [FileMan 130,127]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamewasSeqCompressDeviceUsed
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::wasSeqCompressDeviceUsed
Stereotype
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 wasTimeOutVerified
Public Boolean wasTimeOutVerified

Indicates whether a "Time Out" verification process was conducted prior to the start of the procedure. A designated member of the OR team states the name of the patient, the procedure to be performed, the location of the site (including laterality if applicable), and the specifications of the implant to be used (if applicable). At a minimum, this process must include the surgeon the circulating nurse, and the anesthesia provider. If the answer is No, a justification should be documented in the [Verification] Comments. [FileMan 130,71]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamewasTimeOutVerified
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::wasTimeOutVerified
Stereotype
Template Parameter
TypeBoolean
Upper1
Upper Value(1)
VisibilityPublic


 woundClassification
Public «CS» Code woundClassification

Indicates whether the wound has been classified by the primary surgeon as:
Class 1 - Clean: Respiratory, alimentary, genital, or uninfected urinary tracts are not entered. Uninfected surgical wounds. No inflammation is encountered. Closed primarily and, if necessary, drained with closed drainage. Surgical incisional wounds that occur with nonpenetrating (e.g., blunt) trauma should be included in this category if they meet the criteria. [No hollow organ (e.g. bladder, stomach, vagina, lung, etc.) is entered; no breaks in aseptic technique.]
Class 2 - Clean/Contaminated: Respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major breaks in technique are encountered. (Hollow organ entered but controlled; no inflammation; primary wound closure; minor break in aseptic technique; mechanical drain used.)
Class 3 - Contaminated: Open fresh, accidental (e.g. traumatic) wounds. Procedures that have major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.
Class 4 - Dirty/Infected: Old traumatic wounds that have retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the surgical field before the procedure. (Untreated, uncontrolled spillage from an internal organ; pus in operative wound; open suppurative wound; severe inflammation.)
[FileMan 130,1.09]

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
Class«EntryPoint» SurgeryPerformed
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamewoundClassification
Name Expression
Namespace«EntryPoint» SurgeryPerformed
Opposite
Owner«EntryPoint» SurgeryPerformed
Owning Association
Owning Template Parameter
Qualified NameFHIM::Surgery::SurgeryPerformed::woundClassification
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic