Clinical Resources

Procedure

Overview

The Procedure section captures medical or surgical interventions that a patient has undergone. Documenting procedural history provides critical context for ongoing care, helps avoid redundant interventions, and supports clinical decision-making. Accurate tracking of procedures ensures continuity of care, informs risk assessments, and contributes to population health analytics.

Clinical Data in Source Documents

Procedural information in clinical records is often highly unstructured. It may appear in narrative text within sections like Surgical History, Procedures Performed, or Operative Reports. Examples include:

• Mentions of procedures embedded within free-text notes, such as “Patient underwent cataract removal last year” or “Stent placement performed in 2013.”
• Variations in naming, spelling, and terminology across providers, e.g., “laser sugery repair” vs. “laser surgery procedure.”
• Dates and additional context (e.g., laterality, method, complications) may appear inconsistently or be missing entirely.

The unstructured nature of these records makes automated extraction essential to ensure consistent capture of procedural history across diverse source documents.

JSON Output

The platform extracts procedure data into a standardized JSON format for machine-readable consistency. Each procedure record includes:

• Name: The clinical name of the procedure performed (e.g., cataract removed, laser surgery repair).
• Year of Procedure: The year the procedure was performed, if available.

This structured output enables downstream systems to track procedural history accurately, support analytics, integrate with EHRs, and provide clinical decision support.

{
  "procedures": [
    {
      "name": "Colonoscopy",
      "section_header": "Past Surgical History",
      "year_of_procedure": 2020,
      "page_number": 1
    }
  ]
}

FHIR Output

Extracted procedure data is transformed into a FHIR Procedure resource to facilitate interoperability. Key mappings include:

• Procedure Name → Procedure.code.text – Captures the clinical name of the procedure.
• Status → Procedure.status – Typically set to “completed” to indicate the procedure was performed.
• Category → Procedure.category – Classified as “surgery” using standard HL7 procedure categories.
• Patient Reference → Procedure.subject – Links the procedure to the associated patient record.
• Encounter Reference → Procedure.encounter – Connects the procedure to the relevant clinical encounter.
• Performer → Procedure.performer.actor – Identifies the clinician who performed the procedure.

{
  "fullUrl": "urn:uuid:1e9ad6aa-5e31-4dd6-b4c3-43f01ed614ae",
  "resource": {
    "resourceType": "Procedure",
    "status": "completed",
    "code": {
      "text": "Colonoscopy"
    },
    "subject": {
      "reference": "Patient/b17aaab1-311c-4d98-9c93-030277d0aeb0"
    },
    "encounter": {
      "reference": "Encounter/d4ebe08e-6db9-429a-958a-ed5a1de4cffa"
    },
    "occurrenceDateTime": "2020",
    "performer": [
      {
        "actor": {
          "reference": "Practitioner/9a1de72f-33fd-47d9-a0b9-b34d26985db8"
        }
      }
    ],
    "id": "1e9ad6aa-5e31-4dd6-b4c3-43f01ed614ae"
  }
}