Surgery record information module

 

Element structure

namespaces declaration

The namespaces declaration for this module is as follows:

xmlns:mmlSg="http://www.medxml.net/MML/ContentModule/Surgery/1.0"

 

Element list

 

Elements

Attribute

Datatypes

Occurrence

Table id

1

mmlSg:SurgeryModule

 

 

 

 

1.1.

Å 

mmlSg:surgeryItem

 

 

+

 

1.1.1.

Å 

Å 

mmlSg:surgicalInfo

 

 

 

 

 

 

 

 

 

 

 

 

mmlSg:type

string

#IMPLIED

MML0021

1.1.1.1.

Å 

Å 

Å 

mmlSg:date

 

date

 

 

1.1.1.2.

Å 

Å 

Å 

mmlSg:startTime

 

time

?

 

1.1.1.3.

Å 

Å 

Å 

mmlSg:duration

 

timePeriod

?

 

1.1.1.4.

Å 

Å 

Å 

mmlSg:surgicalDepartment

 

 

?

 

1.1.1.4.1.

Å 

Å 

Å 

Å 

mmlDp:Department

 

 

 

 

1.1.1.5.

Å 

Å 

Å 

mmlSg:patientDepartment

 

 

?

 

1.1.1.5.1.

Å 

Å 

Å 

Å 

mmlDp:Department

 

 

 

 

1.1.2.

Å 

Å 

mmlSg:surgicalDiagnosis

 

 

 

 

1.1.2.1.

Å 

Å 

Å 

mmlRd:RegisteredDiagnosisModule

 

 

+

 

1.1.3.

Å 

Å 

mmlSg:surgicalProcedure

 

 

 

 

1.1.3.1.

Å 

Å 

Å 

mmlSg:procedureItem

 

 

+

 

1.1.3.1.1.

Å 

Å 

Å 

Å 

mmlSg:operation

 

string

 

 

 

 

 

 

 

 

 

 

mmlSg:code

string

#IMPLIED

 

 

 

 

 

 

 

 

 

mmlSg:system

string

#IMPLIED

 

1.1.3.1.2.

Å 

Å 

Å 

Å 

mmlSg:operationElement

 

 

?

 

1.1.3.1.2.1.

Å 

Å 

Å 

Å 

Å 

mmlSg:operationElementItem

 

 

+

 

1.1.3.1.2.1.1.

Å 

Å 

Å 

Å 

Å 

Å 

mmlSg:title

 

string

 

 

 

 

 

 

 

 

 

 

mmlSg:code

string

#IMPLIED

 

 

 

 

 

 

 

 

 

mmlSg:system

string

#IMPLIED

 

1.1.3.1.3.

Å 

Å 

Å 

Å 

mmlSg:procedureMemo

 

string

?

 

1.1.4.

Å 

Å 

mmlSg:surgicalStaffs

 

 

?

 

1.1.4.1.

Å 

Å 

Å 

mmlSg:staff

 

 

+

 

 

 

 

 

 

 

 

 

mmlSg:staffClass

string

#IMPLIED

MML0022

 

 

 

 

 

 

 

 

mmlSg:superiority

integer

#IMPLIED

 

1.1.4.1.1.

Å 

Å 

Å 

Å 

mmlSg:staffInfo

 

 

 

 

1.1.4.1.1.1.

Å 

Å 

Å 

Å 

Å 

mmlPsi:PersonalizedInfo

 

 

 

 

1.1.5.

Å 

Å 

mmlSg:anesthesiaProcedure

 

 

?

 

1.1.5.1.

Å 

Å 

Å 

mmlSg:title

 

string

+

 

 

Å 

Å 

Å 

Å 

Å 

Å 

Å 

mmlSg:code

string

#IMPLIED

 

 

Å 

Å 

Å 

Å 

Å 

Å 

Å 

mmlSg:system

string

#IMPLIED

 

1.1.6.

Å 

Å 

mmlSg:anesthesiologists

 

 

?

 

1.1.6.1.

Å 

Å 

Å 

mmlSg:staff

 

 

*

 

 

Å 

Å 

Å 

Å 

Å 

Å 

Å 

mmlSg:staffClass

string

#IMPLIED

MML0023

 

Å 

Å 

Å 

Å 

Å 

Å 

Å 

mmlSg:superiority

integer

#IMPLIED

 

1.1.6.1.1.

Å 

Å 

Å 

Å 

mmlSg:staffInfo

 

 

 

 

1.1.6.1.1.1.

Å 

Å 

Å 

Å 

Å 

mmlPsi:PersonalizedInfo

 

 

 

 

1.1.7.

Å 

Å 

mmlSg:anesthesiaDuration

 

timePeriod

?

 

1.1.8.

Å 

Å 

mmlSg:operativeNotes

 

string

?

 

1.1.9.

Å 

Å 

mmlSg:referenceInfo

 

 

?

 

1.1.9.1.

Å 

Å 

Å 

mmlCm:extRef

 

 

+

 

1.1.10.

Å 

Å 

mmlSg:memo

 

string

?

 


Occurrence None: 1 appearance without fail, ?: 0 or 1 appearance, +: 1 or more appearances, *: 0 or more appearances
#REQUIRED: Mandatory attribute, #IMPLIED: Omissible attribute

 

Element explanation

1.mmlSg:SurgeryModule

[Detail] Surgery record information. Pay attention to granularity of the surgery and repetition. For surgeries with different dates, MmlModuleItem of MmlBody in the MML structure should be repeated. A series of operations performed almost in the same period is described in one mmlSg:SurgeryModule. If multiple surgical procedures are performed in a series of operations, mmlSg:surgeryItem (1.1.) should be repeated.

 

1.1.mmlSg:surgeryItem

[Detail] Element for input of individual surgery in a series of operations

[Omission] Not allowed

[Repetition setting] Repeated. If multiple surgeries are performed in a series of operations, the data should be repeated. (Example: If surgeries for lobectomy and aortic reconstruction due to abdominal aortic aneurysm have been performed at the same time, each surgical procedure is described in different mmlSg:surgeryItem.)

1.1.1.mmlSg:surgicalInfo

[Detail] Surgical header information

[Omission] Not allowed

[Attribute]

Attribute name

Data type

Omission

Table used

Explanation

mmlSg:type

string

#IMPLIED

MML0021

Surgery type code


[Example] For elective surgery

<mmlSg:surgicalInfo mmlSg:type = " elective ">

 

1.1.1.1.mmlSg:date

[Detail] Surgery date

[Data type] date Format: CCYY-MM-DD

[Omission] Not allowed

 

1.1.1.2.mmlSg:startTime

[Detail] Surgery start time

[Data type] time Format: hh:mm:ss
Normally, the time can be reduced to hours and minute (hh:mm).

[Omission] Omission allowed

[Example]

<mmlSg:startTime>08:30</mmlSg:startTime>

 

1.1.1.3.mmlSg:duration

[Detail] Surgery duration

[Data type] timePeriod Format: PnYnMnDTnHnMnS
Usually, the format is PTnHnM.

[Omission] Omission allowed

[Example] 5 hours 25 minutes

<mmlSg:duration>PT5H25M</mmlSg:duration>

 

1.1.1.4.mmlSg:surgicalDepartment

[Detail] Surgical department information

[Omission] Omission allowed

 

1.1.1.4.1.mmlDp:Department

[Detail] Surgical department. Refer to the MML common format for the structure.

[Omission] Not allowed

 

1.1.1.5.mmlSg:patientDepartment

[Detail] Patient department information. Since the patient department may be different from the surgical department, the patient department can be input.

[Omission] Omission allowed

 

1.1.1.5.1.mmlDp:Department

[Detail] Department to which the patient belonged at the time of surgery. Refer to the MML common format.

[Omission] Not allowed

[Example] When the patient belongs to 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

[Detail] Diagnostic information after surgery. Considering the especial surgical diagnosis such as Classification of Carcinoma, the data can be input separately from mmlRd:RegisteredDiagnosisModule. However, the structure should be the same.

[Omission] Not allowed

 

1.1.2.1.mmlRd:RegisteredDiagnosisModule

[Detail] Refer to the above for the structure.

[Omission] Not allowed

[Repetition setting] Repeated. If there are multiple diagnosis names after surgery, the data should be repeated.Å@

[Example] 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

[Detail] Surgical procedure information

[Omission] Not allowed

 

1.1.3.1.mmlSg:procedureItem

[Detail] Element to express repetition of surgical procedure. Select either expression of the entire procedure (1.1.3.1.1.) including modifiers or separate expression of surgical element (1.1.3.1.2.) in one mmlSg:procedureItem.

[Omission] Not allowed

[Repetition setting] Repeated. If multiple procedures are used for a surgery, the data should be repeated. (Example: Coronary bypass grafting and cardio-pulmonary bypass)

 

1.1.3.1.1.mmlSg:operation

[Detail] Surgical procedure. Express the entire procedure including modifiers.

[Data type] string

[Omission] If a separate expression (1.1.3.1.2.) is selected, omission is allowed.

[Attribute]

Attribute name

Data type

Omission

Explanation

mmlSg:code

string

#IMPLIED

Surgical procedure code

mmlSg:system

string

#IMPLIED

Surgical procedure code system name


[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

[Detail] Separate expression of surgical operation element

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 entire expression (1.1.3.1.1.) including modifiers is selected, omission is allowed.

 

1.1.3.1.2.1.mmlSg:operationElementItem

[Detail] Element to express repetition of element

[Omission] Not allowed

[Repetition setting] Repeated. The data should be repeated for the number of elements.

 

1.1.3.1.2.1.1.mmlSg:title

[Detail] Separated operation title

[Data type] string

[Omission] Not allowed

[Attribute]

Attribute name

Data type

Omission

Explanation

mmlSg:code

string

#IMPLIED

Surgery procedure code

mmlSg:system

string

#IMPLIED

Surgery procedure code system name

 

1.1.3.1.3.mmlSg:procedureMemo

[Detail] Memo for surgical procedure

[Data type] string

[Omission] Omission allowed

[Example] Coronary artery bypass grafting, 3 vessel bypass, cardio-pulmonary bypass and 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

[Detail] Surgical staff information except anesthesia staff

[Omission] Omission allowed

 

1.1.4.1.mmlSg:staff

[Detail] Element for repetition

[Omission] Not allowed

[Repetition setting] Repeated. The data should be repeated for the number of staff.

[Attribute]

Attribute name

Data type

Omission

Table used

Explanation

mmlSg:staffClass

string

#IMPLIED

MML0022

Class of surgical staff

mmlSg:superiority

integer

#IMPLIED

 

Superiority

Superiority means “First” or “Second” assistant. It should be indicated by an integer.

[Example] First assistant

<mmlSg:staff mmlSg:superiority = "1" mmlSg:staffClass = " assistant">

 

1.1.4.1.1.mmlSg:staffInfo

[Detail] Staff ID information

[Omission] Not allowed

 

1.1.4.1.1.1.mmlPsi:PersonalizedInfo

[Detail] Personal identification information. Refer to mmlPsi:PersonalizedInfo above.

[Omission] Not allowed

 

1.1.5.mmlSg:anesthesiaProcedure

[Detail] Anesthesia procedure information

[Omission] Omission allowed

 

1.1.5.1.mmlSg:title

[Detail] Anesthesia procedure title

[Data type] string

[Omission] Not allowed

[Repetition setting] Repeated. If multiple anesthesia procedures are available, the data should be repeated.

[Attribute]

Attribute name

Data type

Omission

Explanation

mmlSg:code

string

#IMPLIED

Anesthesia procedure code

mmlSg:system

string

#IMPLIED

Anesthesia procedure code system name


[Example] General anesthesia, tracheal 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

[Detail] Anesthesiologist information

[Omission] Not allowed

 

1.1.6.1.mmlSg:staff

[Detail] Anesthesiologist

[Omission] Omission allowed

[Repetition setting] Repeated. If multiple anesthesiologists are available, the data should be repeated.

[Attribute]

Attribute name

Data type

Omission

Table used

Explanation

mmlSg:staffClass

string

#IMPLIED

MML0023

Class of anesthesiologist

mmlSg:superiority

integer

#IMPLIED

 

Superiority

 

1.1.6.1.1.mmlSg:staffInfo

[Detail] Anesthesiologist ID information

[Omission] Not allowed

 

1.1.6.1.1.1.mmlPsi:PersonalizedInfo

[Detail] Personal identification information. Refer to mmlPsi:PersonalizedInfo above.

[Omission] Not allowed

 

1.1.7.mmlSg:anesthesiaDuration

[Detail] Anesthesia duration

[Data type] timePeriod Format: PnYnMnDTnHnMnS
Normally, the format should be PTnHnM.ÅD

[Omission] Omission allowed

[Example] 6 hours 25 minutes

<mmlSg:anesthesiaDuration> PT6H25M </mmlSg:anesthesiaDuration>

 

1.1.8.mmlSg:operativeNotes

[Detail] Free note of operation record

[Data type] string

[Omission] Omission allowed

[Document layout] Use of XHTML allowed

 

1.1.9.mmlSg:referenceInfo

[Detail] External reference of illustrations and photos used for operation record

[Omission] Omission allowed

 

1.1.9.1.mmlCm:extRef

[Detail] Refer to the MML common format (external reference format) for the structure.

[Omission] Not allowed

[Repetition setting] Repeated. The data should be repeated for the number of multiple external references, if available.

[Example] Surgical 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

[Detail] Memo for surgery

[Data type] string

[Omission] Omission allowed