11. 8. Surgery record information
module
Namespace declaration
Namespace declaration of this module is as follows.
xmlns:mmlSg="http://www.medxml.net/MML/ContentModule/Surgery/1.0"
Element list
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Element
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Attribute
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Data type
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Occurrence
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Table
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1.
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mmlSg:SurgeryModule
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1.1.
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mmlSg:surgeryItem
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+
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1.1.1.
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mmlSg:surgicalInfo
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mmlSg:type
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string
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#IMPLIED
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MML0021
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1.1.1.1.
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mmlSg:date
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date
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1.1.1.2.
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mmlSg:startTime
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time
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?
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1.1.1.3.
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mmlSg:duration
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timePeriod
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?
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1.1.1.4.
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mmlSg:surgicalDepartment
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?
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1.1.1.4.1.
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mmlDp:Department
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1.1.1.5.
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mmlSg:patientDepartment
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?
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1.1.1.5.1.
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mmlDp:Department
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1.1.2.
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mmlSg:surgicalDiagnosis
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1.1.2.1.
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mmlRd:RegisteredDiagnosisModule
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+
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1.1.3.
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mmlSg:surgicalProcedure
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1.1.3.1.
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mmlSg:procedureItem
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+
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1.1.3.1.1.
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mmlSg:operation
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string
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mmlSg:code
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string
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#IMPLIED
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mmlSg:system
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string
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#IMPLIED
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1.1.3.1.2.
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mmlSg:operationElement
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?
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1.1.3.1.2.1.
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mmlSg:operationElementItem
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+
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1.1.3.1.2.1.1.
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mmlSg:title
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string
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mmlSg:code
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string
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#IMPLIED
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mmlSg:system
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string
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#IMPLIED
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1.1.3.1.3.
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mmlSg:procedureMemo
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string
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?
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1.1.4.
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mmlSg:surgicalStaffs
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?
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1.1.4.1.
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mmlSg:staff
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+
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mmlSg:staffClass
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string
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#IMPLIED
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MML0022
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mmlSg:superiority
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integer
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#IMPLIED
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1.1.4.1.1.
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mmlSg:staffInfo
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1.1.4.1.1.1.
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mmlPsi:PersonalizedInfo
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1.1.5.
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mmlSg:anesthesiaProcedure
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?
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1.1.5.1.
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mmlSg:title
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string
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+
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mmlSg:code
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string
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#IMPLIED
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mmlSg:system
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string
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#IMPLIED
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1.1.6.
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mmlSg:anesthesiologists
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?
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1.1.6.1.
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mmlSg:staff
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*
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mmlSg:staffClass
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string
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#IMPLIED
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MML0023
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mmlSg:superiority
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integer
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#IMPLIED
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1.1.6.1.1.
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mmlSg:staffInfo
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1.1.6.1.1.1.
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mmlPsi:PersonalizedInfo
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1.1.7.
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mmlSg:anesthesiaDuration
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timePeriod
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?
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1.1.8.
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mmlSg:operativeNotes
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string
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?
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1.1.9.
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mmlSg:referenceInfo
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?
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1.1.9.1.
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mmlCm:extRef
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+
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1.1.10.
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mmlSg:memo
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string
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?
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Occurrence; blank: 1 appearance without fail, ?: 0 or 1 appearance, +: 1 or more appearances, *: 0 or more appearances
#REQUIRED: Required attribute, #IMPLIED: Omissible attribute
1.mmlSg:SurgeryModule
Description: surgery record information.
Attention should be paid to the granularity of surgeries and element repetition.
For the description of different surgeries with apparently different dates,
<paragraph> should be repeated. A series of operations performed almost
at the same time should be described in one mmlSg:SurgeryModule. If multiple
surgical procedures are performed in a series of operation, the mmlSg:surgeryItem
(1.1.) should be repeated.
1.1.mmlSg:surgeryItem
Description: element for the input
of an individual surgery in a series of operation
Omission: not allowed
Repetition: allowed. If multiple
surgeries are performed in a series of operation, the element should be repeated.
(Example: if surgeries of lobectomy and aorta replacement with a synthetic
graft due to abdominal aortic aneurysm are performed at the same time, each
surgical procedure is described in a different mmlSg:surgeryItem.)
1.1.1.mmlSg:surgicalInfo
Description: surgery header information
Omission: not allowed
Attribute:
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Attribute name
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Data type
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Omission
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Table
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Remarks
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mmlSg:type
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string
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#IMPLIED
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MML0021
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Surgery type code
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Example: a case of an elective
surgery
<mmlSg:surgicalInfo mmlSg:type = " elective ">
1.1.1.1.mmlSg:date
Description: surgery date
Data type: date Format: CCYY-MM-DD
Omission: not allowed
1.1.1.2.mmlSg:startTime
Description: surgery start time
Data type: time Format: hh:mm:ss
Normally, time can be shortened to hours
and minutes (hh:mm).
Omission: allowed
Example:
<mmlSg:startTime>08:30</mmlSg:startTime>
1.1.1.3.mmlSg:duration
Description: surgery duration
Data type: timePeriod Format: PnYnMnDTnHnMnS
Usually, the PTnHnM form is used.
Omission: allowed
Example: duration of 5 hours and
25 minutes
<mmlSg:duration>PT5H25M</mmlSg:duration>
1.1.1.4.mmlSg:surgicalDepartment
Description: surgery operating department
information
Omission: allowed
1.1.1.4.1.mmlDp:Department
Description: surgery operating
department. Refer to the MML common format for the structure.
Omission: not allowed
1.1.1.5.mmlSg:patientDepartment
Description: patient department information.
Since the patient department may be different from the surgery-operating department,
the patient department information can be entered here.
Omission: allowed
1.1.1.5.1.mmlDp:Department
Description: department to which
a patient belonged at the time of surgery. Refer to the MML common format
for the structure.
Omission: not allowed
Example: when the patient belongs
to the internal medicine (ID 01).
<mmlDp:Department>
<mmlDp:name mmlDp:repCode = "A" mmlDp:tableId = "MML0025">
Internal medicine
</mmlDp:name>
<mmlCm:Id mmlCm:type = "medical" mmlCm:tableId = "MML0029">01</mmlCm:Id>
</mmlDp:Department>
1.1.2.mmlSg:surgicalDiagnosis
Description: surgical diagnosis
information. Considering diagnoses particular to surgeries, such as Classification
of Carcinoma, surgical diagnosis information can be entered separately from
the mmlRd:RegisteredDiagnosisModule. However, the structure should be the
same.
Omission: not allowed
1.1.2.1.mmlRd:RegisteredDiagnosisModule
Description: refer to the aforementioned
explanation for the structure.
Omission: not allowed
Repetition: allowed. If multiple
diagnoses are available, the element should be repeated.
Example: a case of upper right
lung cancer
<mmlSg:surgicalDiagnosis>
<mmlRd:RegisteredDiagnosisModule>
<mmlRd:diagnosisContents>
<mmlRd:dxItem >
<mmlRd:name mmlRd:code = " C349-.007" mmlRd:system = "ICD10">
Lung cancer
</mmlRd:name>
</mmlRd:dxItem>
<mmlRd:dxItem>
<mmlRd:name>right</mmlRd:name>
</mmlRd:dxItem>
<mmlRd:dxItem >
<mmlRd:name>upper lobe</mmlRd:name>
</mmlRd:dxItem>
</mmlRd:diagnosisContents>
<mmlRd:categories>
<mmlRd:category mmlRd:tableId = "MML0012">mainDiagnosis</mmlRd:category>
<mmlRd:category mmlRd:tableId = "MML0013">academicDiagnosis</mmlRd:category>
<mmlRd:category mmlRd:tableId = "MML0014">operativeDiagnosis</mmlRd:category>
<mmlRd:category mmlRd:tableId = "MML0015">confirmedDiagnosis</mmlRd:category>
</mmlRd:categories>
</mmlRd:RegisteredDiagnosisModule>
</mmlSg:surgicalDiagnosis>
1.1.3.mmlSg:surgicalProcedure
Description: surgical procedure information
Omission: not allowed
1.1.3.1.mmlSg:procedureItem
Description: element for repetition
of surgical procedures. Select either the full expression (1.1.3.1.1.) of
the entire procedures including modifiers or separated element expression
(1.1.3.1.2.) of surgical procedures in one mmlSg:procedureItem.
Omission: not allowed
Repetition: allowed. If multiple
procedures are used for a surgery, the element should be repeated. (Example:
coronary bypass grafting and cardio-pulmonary bypass)
1.1.3.1.1.mmlSg:operation
Description: surgical procedure.
Full expression of the entire procedure including modifiers.
Data type: string
Omission: If the separated expression
(1.1.3.1.2.) of elements is selected, omission is allowed.
Attribute:
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Attribute name
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Data type
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Omission
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Remarks
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mmlSg:code
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string
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#IMPLIED
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Surgical procedure code
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mmlSg:system
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string
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#IMPLIED
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Surgical procedure code
system name
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Example: coronary bypass grafting
and cardio-pulmonary bypass
<mmlSg:surgicalProcedure>
<mmlSg:procedureItem>
<mmlSg:operation>coronary artery bypass grafting</mmlSg:operation>
</mmlSg:procedureItem>
<mmlSg:procedureItem>
<mmlSg:operation>cardio-pulmonary bypass</mmlSg:operation>
</mmlSg:procedureItem>
</mmlSg:surgicalProcedure>
1.1.3.1.2.mmlSg:operationElement
Description: separated expression
of surgical elements
Example: right mastectomy is separated
into right and mastectomy.
Example: coronary artery 3 vessel
bypass grafting is separated into coronary artery bypass grafting and 3 vessel
bypass grafting.
Omission: If the full expression
(1.1.3.1.1.) including modifiers is selected, omission is allowed.
1.1.3.1.2.1.mmlSg:operationElementItem
Description: element for repetition
of surgical elements.
Omission: not allowed
Repetition: allowed. The element should be repeated the same number of times as the number of elements.
1.1.3.1.2.1.1.mmlSg:title
Description: title of a separated
operation element
Data type: string
Omission: not allowed
Attribute:
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Attribute name
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Data type
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Omission
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Remarks
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mmlSg:code
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string
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#IMPLIED
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Surgical procedure code
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mmlSg:system
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string
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#IMPLIED
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Surgical procedure code system name
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1.1.3.1.3.mmlSg:procedureMemo
Description: memo for surgical procedures
Data type: string
Omission: allowed
Example: procedures of coronary
artery bypass grafting, 3 vessel bypass
and cardio-pulmonary bypass, retrograde
blood cardioplegia (no blood transfusion)
<mmlSg:surgicalProcedure>
<mmlSg:procedureItem>
<mmlSg:operationElement>
<mmlSg:operationElementItem>
<mmlSg:title> coronary artery bypass grafting </mmlSg:title>
</mmlSg:operationElementItem>
<mmlSg:operationElementItem>
<mmlSg:title>3 vessels (LIMA to LAD, SVGs to #9, #12) </mmlSg:title>
</mmlSg:operationElementItem>
</mmlSg:operationElement>
</mmlSg:procedureItem>
<mmlSg:procedureItem>
<mmlSg:operationElement>
<mmlSg:operationElementItem>
<mmlSg:title> cardio-pulmonary bypass</mmlSg:title>
</mmlSg:operationElementItem>
<mmlSg:operationElementItem>
<mmlSg:title> retrograde blood cardioplegia</mmlSg:title>
</mmlSg:operationElementItem>
</mmlSg:operationElement>
<mmlSg:procedureMemo>no blood transfusion </mmlSg:procedureMemo>
</mmlSg:procedureItem>
</mmlSg:surgicalProcedure>
1.1.4.mmlSg:surgicalStaffs
Description: surgery staff information
except anesthesia staff
Omission: allowed
1.1.4.1.mmlSg:staff
Description: element for repetition
Omission: not allowed
Repetition: allowed. The element
should be repeated the same number of times as the number of staff.
Attribute:
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Attribute name
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Data type
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Omission
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Table
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Remarks
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mmlSg:staffClass
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string
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#IMPLIED
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MML0022
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Classification of surgery
staff
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mmlSg:superiority
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integer
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#IMPLIED
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Superiority
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Superiority means ranking such as
“First” or “Second” assistant. It should be specified with an integer.
Example: a case of the first assistant
<mmlSg:staff mmlSg:superiority = "1" mmlSg:staffClass = " assistant">
1.1.4.1.1.mmlSg:staffInfo
Description: surgery staff ID information
Omission: not allowed
1.1.4.1.1.1.mmlPsi:PersonalizedInfo
Description: personal identification
information. Refer to the aforementioned mmlPsi:PersonalizedInfo.
Omission: not allowed
1.1.5.mmlSg:anesthesiaProcedure
Description: anesthesia procedure
information
Omission: allowed
1.1.5.1.mmlSg:title
Description: anesthesia procedure
title
Data type: string
Omission: not allowed
Repetition: allowed. If multiple
anesthesia procedures are available, the element should be repeated.
Attribute:
|
Attribute name
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Data type
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Omission
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Remarks
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mmlSg:code
|
string
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#IMPLIED
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Anesthesia procedure
code
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mmlSg:system
|
string
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#IMPLIED
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Anesthesia procedure
code system name
|
Example: general anesthesia, endotracheal
intubation and G+O+Ethrane anesthesia
<mmlSg:anesthesiaProcedure>
<mmlSg:title>general anesthesia</mmlSg:title>
<mmlSg:title>tracheal intubation </mmlSg:title>
<mmlSg:title>G+O+Ethrane</mmlSg:title>
</mmlSg:anesthesiaProcedure>
1.1.6.mmlSg:anesthesiologists
Description: anesthesiologist information
Omission: not allowed
1.1.6.1.mmlSg:staff
Description: anesthesiologist
Omission: allowed
Repetition: allowed. If multiple
anesthesiologists are available, the element should be repeated.
Attribute:
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Attribute name
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Data type
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Omission
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Table
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Remarks
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mmlSg:staffClass
|
string
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#IMPLIED
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MML0023
|
Classification of anesthesiologists
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mmlSg:superiority
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integer
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#IMPLIED
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Superiority
|
1.1.6.1.1.mmlSg:staffInfo
Description: anesthesiologist ID
information
Omission: not allowed
1.1.6.1.1.1.mmlPsi:PersonalizedInfo
Description: personal identification
information. Refer to the aforementioned mmlPsi:PersonalizedInfo.
Omission: not allowed
1.1.7.mmlSg:anesthesiaDuration
Description: anesthesia duration
Data type: timePeriod Format: PnYnMnDTnHnMnS
Usually, PTnHnM form is used.
Omission: allowed
Example: duration of 6 hours and
25 minutes
<mmlSg:anesthesiaDuration> PT6H25M </mmlSg:anesthesiaDuration>
1.1.8.mmlSg:operativeNotes
Description: free note of operation
record
Data type: string
Omission: allowed
Document layout: use of XHTML is allowed.
1.1.9.mmlSg:referenceInfo
Description: external references
of illustrations and photos used for operation record.
Omission: allowed
1.1.9.1.mmlCm:extRef
Description: refer to the MML common
format (External reference format) for the structure.
Omission: not allowed
Repetition: allowed. If multiple
external references are available, the element should be repeated the number
of times.
Example: surgical record figure
(Fig. 1: Skin incision)
<mmlSg:referenceInfo>
<mmlCm:extRef mmlCm:contentType = "image/gif"
mmlCm:medicalRole = " surgicalFigure "
mmlCm:title = "Fig1. Skin incision"
mmlCm:href = "patient001/surgicalFigure001.gif"/>
</mmlSg:referenceInfo>
1.1.10.mmlSg:memo
Description: memo for surgery
Data type: string
Omission: allowed
© 2003. All rights reserved
