["Procedure, Performed": "General Surgery"]
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have general surgery procedures.
Inclusion Criteria: Includes only relevant concepts associated with representing general surgery. These surgical procedures are thoracic and abdominal procedures, except for cardiac procedures.
Exclusion Criteria: No exclusions.
Constrained to codes in the Procedure, Performed: General Surgery value set (2.16.840.1.113883.3.117.1.7.1.255)
"Procedure, Performed"
Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.
Two QDM Known Issues has been identified related to this datatype.
- To see the QDM Known Issue related to QDM Procedure, Performed completion time, please click here.
- To see the QDM Known Issue related to Differentiating Elective Vs Emergent or Urgent Procedures, please click here.
Timing:
- relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
- relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
- startTime - The time the procedure begins.
- stopTime - The time the procedure ends.
- author dateTime references the time the action was recorded.
- Refer to the eCQM expression to determine allowable timings to meet measure criterion.
Notes:
- Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
- The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
- negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
- For clarification, see Appendix 6.6 with 2020 guidance about differentiating between successful and unsuccessful procedures.
rank
Rank defines a position in a hierarchy for diagnoses or procedures. It replaces ordinality previously assigned to "Procedure, Performed", "Procedure, Order", and "Procedure, Recommended". ordinality does not align with any FHIR resources; it does align with definitions for FHIR encounter.diagnosis. Thus, the concept fits best consistently across QDM for the concept of principal for encounter diagnosis and for procedure.
The thought process or justification for the datatype. In some measures, specific treatments are acceptable inclusion criteria only if a justified reason is present. Each of these measures uses a value set (often, but not exclusively, using SNOMED CT) to express acceptable justification reasons. Other measures specify reasons as justification for exclusions. Examples include patient, system, or medical-related reasons for declining to perform specific actions. Each of these measures also uses a value set to express acceptable justification reasons for declining to perform expected actions.