majiayu000 Procedures
Generate realistic Procedure resources with proper coding and clinical context.
Coding Systems
Use dual coding when possible:
- CPT (Current Procedural Terminology): system = http://www.ama-assn.org/go/cpt
- SNOMED CT: system = http://snomed.info/sct
- HCPCS: system = https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets
- ICD-10-PCS (inpatient): system = http://www.cms.gov/Medicare/Coding/ICD10
Common Procedures by Specialty
General Surgery:
- 47562 Laparoscopic cholecystectomy (SNOMED 45595009)
- 44970 Laparoscopic appendectomy (SNOMED 80146002)
- 49505 Inguinal hernia repair (SNOMED 44558001)
Orthopedic:
- 27447 Total knee arthroplasty (SNOMED 609588000)
- 27130 Total hip arthroplasty (SNOMED 52734007)
- 27245 ORIF femur fracture (SNOMED 179097006)
- 29881 Knee arthroscopy with meniscectomy (SNOMED 112727005)
Cardiology:
- 93458 Left heart catheterization (SNOMED 41976001)
- 92928 PCI with stent placement (SNOMED 36969009)
- 33533 CABG (SNOMED 232717009)
- 33208 Pacemaker insertion (SNOMED 307280005)
GI / Endoscopy:
- 43239 EGD with biopsy (SNOMED 386810004)
- 45380 Colonoscopy with biopsy (SNOMED 73761001)
- 47563 Lap cholecystectomy with cholangiogram (SNOMED 45595009)
Pulmonary / Critical Care:
- 31600 Tracheostomy (SNOMED 48387007)
- 94002 Mechanical ventilation initiation (SNOMED 40617009)
- 32405 Lung biopsy (SNOMED 15081005)
OB/GYN:
- 59510 Cesarean delivery (SNOMED 11466000)
- 59400 Vaginal delivery (SNOMED 177184002)
- 58661 Laparoscopic salpingectomy (SNOMED 287664005)
Urology:
- 52601 TURP (SNOMED 90199006)
- 50590 Lithotripsy (SNOMED 236990002)
Dermatology / Minor:
- 11102 Skin biopsy punch (SNOMED 240977001)
- 17000 Cryotherapy destruction (SNOMED 26782000)
Radiology (Interventional):
- 36556 Central line insertion (SNOMED 392230005)
- 75625 Aortography (SNOMED 77343006)
Emergency / Bedside:
- 36415 Venipuncture (SNOMED 82078001)
- 12001 Wound repair simple (SNOMED 225358003)
- 31500 Intubation (SNOMED 112798008)
Status
- preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown.
- For not-done: include statusReason (medical contraindication, patient refusal, etc.).
Body Site
Include Procedure.bodySite with SNOMED CT lateralized codes:
- Left knee (82169009), Right hip (62175007), Abdomen (818983003), Chest (51185008), Heart (80891009), Colon (71854001), Lung (39607008).
Outcome
Use Procedure.outcome with codes from http://snomed.info/sct:
- 385669000 Successful, 385671000 Unsuccessful, 385670004 Partially successful.
Complications
Include Procedure.complication and complicationDetail:
- Infection (SNOMED 128241005), Hemorrhage (131148009), Wound dehiscence (225553008).
Performers
- Procedure.performer[].actor → Reference(Practitioner/{id}).
- Procedure.performer[].function — primary surgeon, first assistant, anesthesiologist.
References
- Procedure.subject → Reference(Patient/{id}) — required.
- Procedure.encounter → Reference(Encounter/{id}).
- Procedure.reasonReference → Reference(Condition/{id}) — indication.
- Procedure.report → Reference(DiagnosticReport/{id}) — operative report.
- Procedure.basedOn → Reference(ServiceRequest/{id}).