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C 166 - Operative Note Document Component
The Operative Note Document Component defines a clinical document that enables the exchange of information related to a surgical procedure. It is created following a surgical or other high-risk procedure and records the pre- and post-surgical diagnosis, pertinent events of the procedure, as well as the condition of the patient following the procedure. It is based upon the HL7 Implementation Guide for CDA Release 2: Operative Notes Draft Standard for Trial Use.
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Operative Note Document Component
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© 2009 American National Standards Institute