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Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 1 of 45
Aesthetics
Board Reporting Term Terms that roll up to the Board Reporting Term
Procedure Reporting Field Procedure Reporting Field Values
Abdominoplasty Abdominolipectomy
Abdominoplasty and liposuction
Fleur de Lys abdominoplasty
Mini-abdominoplasty
Upper abdominoplasty
W abdominoplasty
Augmentation genioplasty Forward sliding genioplasty
Reduction genioplasty
Augmentation mammoplasty Augmentation of mammoplasty with graft
Bilateral augmentation mammoplasty
Left augmentation mammoplasty
Right augmentation mammoplasty
Augmentation of buttock
Augmentation rhinoplasty
Blepharoplasty Eyelid Lower
Upper
Upper and Lower
Brachioplasty
Browlift
Chemexfoliation of skin
Circumferential abdominoplasty
Dermabrasion
Epilation
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 2 of 45
Aesthetics
Board Reporting Term Terms that roll up to the Board Reporting Term
Procedure Reporting Field Procedure Reporting Field Values
Facelift operation
Grafting of fat
Injection of botulinum toxin Intramuscular infiltration of botulinum toxin
Injection of sclerosing agent
Labiaplasty
Laser resurfacing of skin
Liposuction of subcutaneous tissue
Mastopexy
Nasal septoplasty
Otoplasty of prominent or protruding ear
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 3 of 45
Aesthetics
Board Reporting Term Terms that roll up to the Board Reporting Term
Procedure Reporting Field Procedure Reporting Field Values
Reduction mammoplasty Reduction mammoplasty central pedicle technique
Reduction mammoplasty free nipple graft technique
Reduction mammoplasty horizontal pedicle technique
Reduction mammoplasty inferior pedicle technique
Reduction mammoplasty superior pedicle technique
Reduction mammoplasty vertical bipedicle technique
Reduction mammoplasty vertical scar technique
Reduction mammoplasty with nipple repositioning, unilateral
Reduction mammoplasty, bilateral
Reduction of buttocks
Repair of blepharoptosis
Rhytidectomy of neck with platysmal tightening
Subcutaneous injection of filling material
Thigh reduction
Zygomatic augmentation Malar augmentation with alloplastic material
Malar augmentation with bone
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 4 of 45
Craniomaxillofacial Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Alveolar bone graft
Augmentation genioplasty Forward sliding genioplasty
Reduction genioplasty
Augmentation rhinoplasty
Bone graft
Closed reduction of malar fracture
Closure of palatal fistula
Drainage of abscess
Facial reanimation surgery Component Fascial sling
Free flap
Local muscle transfer
Nerve graft to facial nerve
Nerve transfer to facial nerve
Other
Irrigation of wound
Lip reconstruction Reconstruction of lip with Abbe flap
Reconstruction of lip with Abbe-Estlander flap
Reconstruction of lip with Karapandizc flap
Reconstruction of lip with local flap
Reconstruction of lip with McGregor flap
Reconstruction of lip with microvascular transferred flap
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 5 of 45
Aesthetics
Board Reporting Term Terms that roll up to the Board Reporting Term
Procedure Reporting Field Procedure Reporting Field Values
Nasal septoplasty
Open reduction maxillary fracture
Open reduction of fracture of mandible with fixation
Open reduction of malar fracture
Osteotomy Type Calvarial
Craniofacial
Maxillofacial
Osteotomy of facial bone Area Mandible
Maxilla
Maxilla and mandible
Other
Pharyngoplasty
Physical examination under general anaesthesia
Primary repair of cleft lip
Primary repair of cleft palate
Reduction of fracture of maxilla
Reduction of fracture of orbital bones Approach Closed
Open
Reduction of fractured nasal bone Approach Closed
Open
Revision of primary closure of cleft lip
Rhinoplasty for cleft lip nasal deformity
Surgical debridement of wound
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 6 of 45
Aesthetics
Board Reporting Term Terms that roll up to the Board Reporting Term
Procedure Reporting Field Procedure Reporting Field Values
Zygomatic augmentation Malar augmentation with alloplastic material
Malar augmentation with bone
Facial soft tissue Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Application of dressing under anaesthesia
Blepharoplasty Eyelid Lower
Upper
Upper and Lower
Browlift
Change of dressing, major
Chemexfoliation of skin
Complex surgical repair of wound
Composite graft
Dermabrasion
Division of frenulum of tongue
Drainage of abscess
Exploration of wound of skin Single or multiple Multiple
Single
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 7 of 45
Facial soft tissue Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
External ear reconstruction Stage First stage
Other
Second Stage
Facelift operation
Grafting of fat
Irrigation of wound
Lip reconstruction Reconstruction of lip with Abbe flap
Reconstruction of lip with Abbe-Estlander flap
Reconstruction of lip with Karapandizc flap
Reconstruction of lip with local flap
Reconstruction of lip with McGregor flap
Reconstruction of lip with microvascular transferred flap
Liposuction of subcutaneous tissue
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 8 of 45
Facial soft tissue Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Nerve graft Harvest of nerve
Harvest of sural nerve
New attachment of nerve
Peripheral nerve graft
Peripheral neuroanastomosis
Secondary microsurgical graft to peripheral nerve
Transplantation of peripheral nerve
Operation on the ear
Physical examination under general anaesthesia
Primary microsurgical graft to peripheral nerve
Reconstruction of eyelid Canthoplasty
Excision of lesion of eyelid by wedge resection
Reconstruction of eyelid with distant skin flap
Reconstruction of eyelid with graft
Reconstruction of eyelid with local skin flap
Reconstruction of eyelid with Tripier skin flap
Reconstruction of eyelid, full-thickness
Repair of blepharoptosis
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 9 of 45
Facial soft tissue Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Repair of ectropion
Repair of entropion
Revision of scar
Subcutaneous injection of filling material
Surgical debridement of wound
Wedge resection of lip
General Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Chemexfoliation of skin
Complete axillary lymphadenectomy
Complex surgical repair of wound
Delay of skin flap Stage First stage
Other
Second Stage
Dermabrasion
Distant flap operation Flap type Abdominal Flap
Cross Leg flap
Groin Flap
Drainage of abscess
Epilation
Escharotomy
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 10 of 45
General Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Excision of lesion of skin Skin lesion Large deep
Large superficial
Small deep
Small superficial
Exploration of wound of skin Single or multiple Multiple
Single
External skeletal fixation procedure
Fasciocutaneous flap operation Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator Fasciotomy
Injection of sclerosing agent
Insertion of tissue expander
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 11 of 45
General Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Irrigation of wound
Liposuction of subcutaneous tissue
Muscle flap operation Flap type Gastrocnemius
Gluteous Maximus
Gracilis
Hamstring
Latissimus Dorsi
Pectoralis Major
Rectus Abdominus
Musculocutaneous flap operation Flap type Gastrocnemius
Gluteous Maximus
Gracilis
Hamstring
Latissimus Dorsi
Pectoralis Major
Rectus Abdominus
Trapezius
Nerve graft Harvest of nerve
Harvest of sural nerve
New attachment of nerve
Peripheral nerve graft
Peripheral neuroanastomosis
Secondary microsurgical graft to peripheral nerve
Transplantation of peripheral nerve
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 12 of 45
General Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Neurolysis
Neurolysis of peripheral nerve
Operation on penis
Perforator flap graft Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Physical examination under general anaesthesia
Primary excision of burnt skin Single or multiple Multiple
Single
Primary microsurgical graft to peripheral nerve
Removal of foreign body
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 13 of 45
General Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Removal of implant
Removal of skin expander from subcutaneous tissue
Repair of nerve Single or multiple Multiple
Single
Revision of scar
Sentinel lymph node biopsy
Subcutaneous injection of filling material
Surgical debridement of wound
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Amputation of upper limb Amputation of finger through metacarpal
Amputation of forearm through radius AND ulna
Amputation of upper arm
Amputation through phalanx of finger
Ray amputation of finger
Application of dressing under anaesthesia
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 14 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Arthrodesis Arthrodesis of carpometacarpal joint of digits, other than thumb
Arthrodesis of carpometacarpal joint of thumb with autograft
Arthrodesis of carpometacarpal joint of thumb with internal fixation
Arthrodesis of distal radioulnar joint and segmental resection of ulna with bone graft
Arthrodesis of finger
Arthrodesis of joint of wrist region
Arthrodesis of metacarpophalangeal joint
Arthrodesis of scaphotrapeziotrapezoid joint
Arthrodesis of wrist joint with sliding graft
Intercarpal fusion
Intercarpal fusion for scapholunate advanced collapse
Intercarpal fusion with autograft
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 15 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Arthroplasty Arthroplasty of carpals with synthetic joint prosthesis
Arthroplasty of carpocarpal joint without implant
Arthroplasty of wrist
Arthroplasty of wrist with synthetic joint prosthesis
Arthroplasty of wrist, pseudoarthrosis type with internal fixation
Arthroplasty with prosthetic replacement of lunate
Arthroplasty with prosthetic replacement of trapezium
Excisional arthroplasty of the wrist
Implantation of Swanson prosthesis of wrist
Microvascular transfer of joint
Total wrist replacement
Arthroplasty of hand Arthroplasty of hand
Arthroplasty of metacarpophalangeal and interphalangeal joint
Arthroplasty of the carpometacarpal joint of the thumb
Bone graft
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 16 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Bone reconstruction Bone graft of scaphoid
Closed reduction of fracture of distal radius and percutaneous fixation using Kirschner wire
Grafting of bone of radius
Internal fixation of bone of radius
Open reduction of fracture of carpal bone with internal fixation
Open reduction of fracture of carpal bone without internal fixation
Open reduction of fracture of radius and ulna with internal fixation
Open reduction of open fracture of radius with internal fixation
Osteotomy of radius, distal third
Reduction of fracture of radius with internal fixation
Carpal tunnel decompression
Change of dressing, major
Closed reduction of dislocation of hand
Closed reduction of fracture of hand Percutaneous skeletal fixation of fracture of metacarpal
Percutaneous skeletal fixation of fracture of phalangeal shaft with manipulation
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 17 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Compartment syndrome decompression of upper limb
Complex reconstruction of wrist and hand
Correction of congenital deformity of hand
Debridement of wound of upper limb Incision and drainage of upper extremity
Drainage of abscess
Drainage of tendon sheath
Endoscopic carpal tunnel release
Endoscopic procedure Arthroscopy of wrist
Arthroscopy of wrist with complete synovectomy
Arthroscopy of wrist with excision of triangular fibrocartilage
Arthroscopy of wrist with internal fixation for fracture
Arthroscopy of wrist with internal fixation for instability
Arthroscopy of wrist with joint debridement
Arthroscopy of wrist with lavage and drainage
Diagnostic arthroscopy of wrist joint
Diagnostic arthroscopy of wrist with synovial biopsy
Escharotomy
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 18 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Escharotomy of burnt skin of upper limb
Excision of ganglion of tendon sheath of hand Single or multiple Multiple
Single
Excision of ganglion of wrist, primary Single or multiple Multiple
Single
Excision of ganglion of wrist, recurrent Single or multiple Multiple
Single
Excision of mucous cyst of finger Single or multiple Multiple
Single
Excision of palmar aponeurosis for Dupuytrens contracture of hand
Palmar fasciectomy using open palm technique
Palmar fasciectomy with z-plasty
Exploration of penetrating wound of extremity
Exploration of penetrating wound of hand
Single or multiple Multiple
Single
Exploration of wound of skin Single or multiple Multiple
Single
External skeletal fixation procedure
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 19 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Fasciocutaneous flap operation Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Fasciotomy
Grafting of tendon of hand
Injection of sclerosing agent
Injection of steroid
Irrigation of wound
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 20 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Nerve graft Harvest of nerve
Harvest of sural nerve
New attachment of nerve
Peripheral nerve graft
Peripheral neuroanastomosis
Secondary microsurgical graft to peripheral nerve
Transplantation of peripheral nerve
Nerve pedicle transfer, first stage
Neurolysis
Neurolysis of peripheral nerve
Neuroplasty of major peripheral nerve of brachial plexus
Open reduction of dislocation of hand
Open reduction of fracture of hand Open reduction of fracture of carpals and metacarpals with internal fixation
Open reduction of fracture of hand and percutaneous fixation using Kirschner wire
Open reduction of fracture of phalanges of hand with internal fixation
Osteotomy of bone of upper limb Osteotomy of carpal bone
Osteotomy of metacarpal bone
Osteotomy of phalanx
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 21 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Peripheral neurorrhaphy Epiperineural suturing of peripheral nerve
Suture of digital nerve of hand
Physical examination under general anaesthesia
Primary decompression of peripheral nerve
Primary microsurgical graft to peripheral nerve
Reattachment of upper extremity Replantation of finger
Replantation of forearm between wrist and elbow after complete amputation
Replantation of hand between wrist and fingers after complete amputation
Replantation of multiple fingers
Replantation of thumb
Replantation of upper arm between elbow and shoulder after complete amputation
Reconstruction of extra-articular ligament for stabilisation of joint
Reconstruction of hand with distant skin flap
Reconstruction of hand with local skin flap
Reconstruction of hand with local skin flap Local flap of skin to finger
Local flap of skin to thumb
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 22 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Reduction of fracture-dislocation
Reimplantation
Release of trigger finger
Repair of extensor muscle of upper limb Single or multiple Multiple
Single Repair of extensor tendon forearm, wrist, hand
Single or multiple Multiple
Single
Repair of flexor muscle of upper limb Single or multiple Multiple
Single
Repair of flexor tendon forearm, wrist, hand Single or multiple Multiple
Single
Repair of ligament Complex reconstruction operations on wrist and hand(excluding arthroplasty)
Suturing of ligament of wrist
Repair of muscle by direct suture
Repair of nail bed
Repair of nerve Single or multiple Multiple
Single
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 23 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Repair of tendon Repair of extensor tendon of hand
Repair of multiple tendons in the extensor compartment of the forearm, wrist or hand
Repair of multiple tendons in the flexor compartment of the forearm, wrist or hand
Suture of flexor tendon of hand
Surgical debridement of wound
Suture of brachial plexus
Sympathectomy of digital artery
Synovectomy Repair of nonunion of scaphoid bone with radial styloidectomy
Selective denervation of peripheral nerve
Synovectomy of hand
Tenolysis Simple tenolysis of flexor tendon of palm
Tenolysis of extensor tendon of forearm
Tenolysis of extensor tendon of wrist
Tenolysis of flexor tendon of forearm
Tenolysis of flexor tendon of wrist
Single or multiple Multiple
Single
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 24 of 45
Hand and upper limb Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Terminalisation of finger Single or multiple Multiple
Single
Transfer of tendon Single or multiple Multiple
Single
Head & neck Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Application of dressing under anaesthesia
Augmentation rhinoplasty
Bone graft
Browlift
Change of dressing, major
Dental surgical procedure
Drainage of abscess
Facial reanimation surgery Component Fascial sling
Free flap
Local muscle transfer
Nerve graft to facial nerve
Nerve transfer to facial nerve
Other
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 25 of 45
Head & neck Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Fasciocutaneous flap operation Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Irrigation of wound
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 26 of 45
Head & neck Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Lip reconstruction Reconstruction of lip with Abbe flap
Reconstruction of lip with Abbe-Estlander flap
Reconstruction of lip with Karapandizc flap
Reconstruction of lip with local flap
Reconstruction of lip with McGregor flap
Reconstruction of lip with microvascular transferred flap
Local flap operation Flap type Cheek
Ear
Eyelid
Lip
Nose
Scalp
Mucosal flap operation Flap type Buccinator
Other
Muscle flap operation Flap type Gastrocnemius
Gluteous Maximus
Gracilis
Hamstring
Latissimus Dorsi
Pectoralis Major
Rectus Abdominus
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 27 of 45
Head & neck Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Musculocutaneous flap operation Flap type Gastrocnemius
Gluteous Maximus
Gracilis
Hamstring
Latissimus Dorsi
Pectoralis Major
Rectus Abdominus
Trapezius
Nasal septoplasty
Neck dissection
Nerve graft Harvest of nerve
Harvest of sural nerve
New attachment of nerve
Peripheral nerve graft
Peripheral neuroanastomosis
Secondary microsurgical graft to peripheral nerve
Transplantation of peripheral nerve
Operation on the ear
Parotidectomy Complete parotidectomy
Superficial parotidectomy
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 28 of 45
Head & neck Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Perforator flap graft Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Physical examination under general anaesthesia
Primary microsurgical graft to peripheral nerve
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 29 of 45
Head & neck Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Reconstruction of nose Reconstruction of nose with bone graft and skin flap
Reconstruction of nose with composite skin graft
Reconstruction of nose with distant flap
Reconstruction of nose with local flap
Reconstruction of nose with microvascular transferred flap
Reconstruction of nose with skin graft
Reconstruction of nose, total with forehead flap
Total or Partial Partial
Total
Repair of nerve Single or multiple Multiple
Single
Rhytidectomy of neck with platysmal tightening
Surgical debridement of wound
Tracheostomy
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 30 of 45
Lower limb & foot Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Application of dressing under anaesthesia
Change of dressing, major
Distant flap operation Flap type Abdominal Flap
Cross Leg flap
Groin Flap
Drainage of abscess
Escharotomy
Exploration of penetrating wound of extremity
Single or multiple Multiple
Single
Exploration of wound of skin Single or multiple Multiple
Single
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 31 of 45
Lower limb & foot Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Fasciocutaneous flap operation Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Fasciotomy
Irrigation of wound
Musculocutaneous flap operation Flap type Gastrocnemius
Gluteous Maximus
Gracilis
Hamstring
Latissimus Dorsi
Pectoralis Major
Rectus Abdominus
Trapezius
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 32 of 45
Lower limb & foot Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Nerve graft Harvest of nerve
Harvest of sural nerve
New attachment of nerve
Peripheral nerve graft
Peripheral neuroanastomosis
Secondary microsurgical graft to peripheral nerve
Transplantation of peripheral nerve
Perforator flap graft Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Physical examination under general anaesthesia
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 33 of 45
Lower limb & foot Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Primary microsurgical graft to peripheral nerve
Primary repair of extensor tendon of lower limb
Single or multiple Multiple
Single
Primary repair of flexor tendon of lower limb Single or multiple Multiple
Single
Reattachment of lower extremity
Reimplantation
Repair of extensor muscle of lower limb Single or multiple Multiple
Single
Repair of flexor muscle of lower limb Single or multiple Multiple
Single
Repair of muscle by direct suture
Repair of tendon
Surgical debridement of wound
Transfer of tendon Single or multiple Multiple
Single
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 34 of 45
Microsurgery Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Breast reconstruction with free flap Flap type DIEP
IGAP
SGAP
SIEA
TRAM
TUG
Distant microvascular transferred flap, fasciocutaneous
Flap type Anterolateral thigh
FDMA
Groin
IGAP
Parascapular
Radial artery
SGAP
Thoracodorsal perforator
Ulnar artery
Distant microvascular transferred flap, myocutaneous
Flap type Gracilis
Inferior gluteal
Lat dorsi
Rectus
Superior gluteal
Distant microvascular transferred flap, osseofasciocutaneous
Flap type DCIA
Fibular
Medial genicular
Radial
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
Prepared by the Royal Australasian College of Surgeons, updated December 2017 Page 35 of 45
Microsurgery Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Distant microvascular transferred flap, osseomyocutaneous
Flap type DCIA
Fibular
Medial genicular o Scapular
Distant muscle microvascular free flap Flap type Gracilis
Lat Dorsi
Rectus Microvascular bone transplantation Flap type DCIA
Fibular
Medial genicular
Radial
Scapular
Microvascular vessel anastomosis Vessel Artery
Vein
Revision of Free Flap
Paediatrics Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Alveolar bone graft
Application of dressing under anaesthesia
Bone graft
Change of dressing, major
Closed reduction of malar fracture
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Paediatrics Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Closure of palatal fistula
Closure of skin by suture Single or multiple Multiple
Single
Complex surgical repair of wound
Division of frenulum of tongue
Drainage of abscess
Exploration of wound of skin Single or multiple Multiple
Single
External ear reconstruction Stage First stage
Other
Second Stage
Glue closure of skin wound Single or multiple Multiple
Single Injection of botulinum toxin Intramuscular infiltration of
botulinum toxin
Insertion of tissue expander
Irrigation of wound
Open reduction of malar fracture
Osteotomy Type Calvarial
Craniofacial
Maxillofacial
Osteotomy of facial bone Area Mandible
Maxilla
Maxilla and mandible
Other
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Paediatrics Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Otoplasty of prominent or protruding ear
Pharyngoplasty
Physical examination under general anaesthesia
Primary repair of cleft lip
Primary repair of cleft palate
Reduction of fracture of orbital bones Approach Closed
Open
Reduction of fractured nasal bone Approach Closed
Open
Removal of skin expander from subcutaneous tissue
Revision of primary closure of cleft lip
Rhinoplasty for cleft lip nasal deformity
Surgical debridement of wound
Skin & integument Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Closure of skin by suture Single or multiple Multiple
Single
Composite graft
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Skin & integument Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Delay of skin flap Stage First stage
Other
Second Stage
Drainage of abscess
Fasciotomy
Full thickness skin graft Single or multiple Multiple
Single
Glue closure of skin wound Single or multiple Multiple
Single
Injection of steroid
Irrigation of wound
Laser resurfacing of skin
Lip reconstruction Reconstruction of lip with Abbe flap
Reconstruction of lip with Abbe-Estlander flap
Reconstruction of lip with Karapandizc flap
Reconstruction of lip with local flap
Reconstruction of lip with McGregor flap
Reconstruction of lip with microvascular transferred flap
Neck dissection
Physical examination under general anaesthesia
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Skin & integument Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Reconstruction of eyelid Canthoplasty
Excision of lesion of eyelid by wedge resection
Reconstruction of eyelid with distant skin flap
Reconstruction of eyelid with graft
Reconstruction of eyelid with local skin flap
Reconstruction of eyelid with Tripier skin flap
Reconstruction of eyelid, full-thickness
Reconstruction of nose Reconstruction of nose with bone graft and skin flap
Reconstruction of nose with composite skin graft
Reconstruction of nose with distant flap
Reconstruction of nose with local flap
Reconstruction of nose with microvascular transferred flap
Reconstruction of nose with skin graft
Reconstruction of nose, total with forehead flap
Total or Partial Partial
Total
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Skin & integument Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Sentinel lymph node biopsy
Split thickness skin graft Skin graft Multiple large
Multiple medium
Multiple small
Single large
Single medium
Single small Surgical debridement of wound
Trunk, perineum & breast Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Abdominoplasty Abdominolipectomy
Abdominoplasty and liposuction
Fleur de Lys abdominoplasty
Mini-abdominoplasty
Upper abdominoplasty
W abdominoplasty
Application of dressing under anaesthesia
Augmentation of buttock
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Trunk, perineum & breast Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Breast reconstruction with free flap Flap type DIEP
IGAP
SGAP
SIEA
TRAM
TUG
Breast reconstruction with muscle or myocutaneous flap
Change of dressing, major
Circumferential abdominoplasty
Debridement of sacral pressure ulcer
Distant flap operation Flap type Abdominal Flap
Cross Leg flap
Groin Flap
Drainage of abscess
Exploration of wound of skin Single or multiple Multiple
Single
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Trunk, perineum & breast Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Fasciocutaneous flap operation Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Gender reassignment surgery
Grafting of fat
Hernia repair Repair of hernia of abdominal wall
Repair of ventral hernia
Repair of ventral hernia using insert of natural material
Repair of ventral hernia using sutures
Repair of ventral hernia with prosthesis or graft
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Trunk, perineum & breast Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Hypospadias repair
Inguinal lymph node dissection
Irrigation of wound
Mastectomy
Mastopexy
Musculocutaneous flap operation Flap type Gastrocnemius
Gluteous Maximus
Gracilis
Hamstring
Latissimus Dorsi
Pectoralis Major
Rectus Abdominus
Trapezius
Nipple reconstruction
Operation on breast
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Trunk, perineum & breast Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Perforator flap graft Flap type Anterolateral high
Deltopectoral
Dorsalis Pedis
FDMA
Groin
IGAP
Intercostal
Lateral Arm
Parascapular
Perineal Flap
Radial Forearm - Reverse
Scapular
SGAP
Supraclavicular
Thoracodorsal Perforator
Physical examination under general anaesthesia
Reconstruction of breast with expander or prosthesis
Stage First stage
Second stage
Single stage
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Plastic and Reconstructive Surgery Aus.
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Trunk, perineum & breast Board Reporting Term Terms that roll up to the Board
Reporting Term Procedure Reporting Field Procedure Reporting Field
Values
Reduction mammoplasty Reduction mammoplasty central pedicle technique
Reduction mammoplasty free nipple graft technique
Reduction mammoplasty horizontal pedicle technique
Reduction mammoplasty inferior pedicle technique
Reduction mammoplasty superior pedicle technique
Reduction mammoplasty vertical bipedicle technique
Reduction mammoplasty vertical scar technique
Reduction mammoplasty with nipple repositioning, unilateral
Reduction mammoplasty, bilateral
Subcutaneous mastectomy
Subcutaneous mastectomy for gynaecomastia
Superficial inguinofemoral lymphadenectomy in continuity with pelvic lymphadenectomy
Superficial inguinofemoral lymphadenectomy including Cloquets node
Surgical debridement of wound
Thigh reduction