|
Procedure
|
|
Definition
|
An
action
that
is
or
was
performed
on
a
patient.
This
can
be
a
physical
intervention
like
an
operation,
or
less
invasive
like
counseling
or
hypnotherapy.
An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
|
|
Control
|
1..1
|
|
Invariants
|
Defined
on
this
element
Defined on this element
pro-1
:
Reason
not
performed
is
only
permitted
if
notPerformed
indicator
is
true
(xpath:
not(exists(f:reasonNotPerformed))
or
f:notPerformed/@value=true())
: Reason not performed is only permitted if notPerformed indicator is true (
expression
: reasonNotPerformed.empty() or notPerformed = true, xpath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true())
|
|
Procedure.identifier
|
|
Definition
|
This
records
identifiers
associated
with
this
procedure
that
are
defined
by
business
processes
and/or
used
to
refer
to
it
when
a
direct
URL
reference
to
the
resource
itself
is
not
appropriate
(e.g.
in
CDA
documents,
or
in
written
/
printed
documentation).
This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).
|
|
Note
|
This
is
a
business
identifer,
not
a
resource
identifier
(see
This is a business identifer, not a resource identifier (see
discussion
)
|
|
Control
|
0..*
|
|
Type
|
Identifier
|
|
Requirements
|
Need
to
allow
connection
to
a
wider
workflow.
Need to allow connection to a wider workflow.
|
|
Summary
|
true
|
|
Procedure.subject
|
|
Definition
|
The
person,
animal
or
group
on
which
the
procedure
was
performed.
The person, animal or group on which the procedure was performed.
|
|
Control
|
1..1
|
|
Type
|
Reference
(
Patient
|
|
Group
)
|
|
Summary
|
true
|
|
Procedure.status
|
|
Definition
|
A
code
specifying
the
state
of
the
procedure.
Generally
this
will
be
in-progress
or
completed
state.
A code specifying the state of the procedure. Generally this will be in-progress or completed state.
|
|
Control
|
1..1
|
|
Binding
|
ProcedureStatus:
A
code
specifying
the
state
of
the
procedure.
(
ProcedureStatus:
A code specifying the state of the procedure.
(
Required
)
|
|
Type
|
code
|
Is
Modifier
Is Modifier
|
true
|
|
Summary
|
true
|
|
Procedure.category
|
|
Definition
|
A
code
that
classifies
the
procedure
for
searching,
sorting
and
display
purposes
(e.g.
"Surgical
Procedure").
A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").
|
|
Control
|
0..1
|
|
Binding
|
Procedure
Category
Codes
(SNOMED
CT):
A
code
that
classifies
a
procedure
for
searching,
sorting
and
display
purposes.
(
Procedure Category Codes (SNOMED CT):
A code that classifies a procedure for searching, sorting and display purposes.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Summary
|
true
|
|
Procedure.code
|
|
Definition
|
The
specific
procedure
that
is
performed.
Use
text
if
the
exact
nature
of
the
procedure
cannot
be
coded
(e.g.
"Laparoscopic
Appendectomy").
The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
|
|
Control
|
1..1
|
|
Binding
|
Procedure
Codes
(SNOMED
CT):
A
code
to
identify
a
specific
procedure
.
(
Procedure Codes (SNOMED CT):
A code to identify a specific procedure .
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Summary
|
true
|
|
Procedure.notPerformed
|
|
Definition
|
Set
this
to
true
if
the
record
is
saying
that
the
procedure
was
NOT
performed.
Set this to true if the record is saying that the procedure was NOT performed.
|
|
Control
|
0..1
|
|
Type
|
boolean
|
Is
Modifier
Is Modifier
|
true
|
Default
Value
Default Value
|
false
|
|
Procedure.reasonNotPerformed
|
|
Definition
|
A
code
indicating
why
the
procedure
was
not
performed.
A code indicating why the procedure was not performed.
|
|
Control
|
0..*
|
|
Binding
|
Procedure
Not
Performed
Reason
(SNOMED-CT):
A
code
that
identifies
the
reason
a
procedure
was
not
performed.
(
Procedure Not Performed Reason (SNOMED-CT):
A code that identifies the reason a procedure was not performed.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Invariants
|
Affect
this
element
Affect this element
pro-1
:
Reason
not
performed
is
only
permitted
if
notPerformed
indicator
is
true
(xpath:
not(exists(f:reasonNotPerformed))
or
f:notPerformed/@value=true())
: Reason not performed is only permitted if notPerformed indicator is true (
expression
: reasonNotPerformed.empty() or notPerformed = true, xpath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true())
|
|
Procedure.bodySite
|
|
Definition
|
Detailed
and
structured
anatomical
location
information.
Multiple
locations
are
allowed
-
e.g.
multiple
punch
biopsies
of
a
lesion.
Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
|
|
Control
|
0..*
|
|
Binding
|
SNOMED
CT
Body
Structures:
Codes
describing
anatomical
locations.
May
include
laterality.
(
SNOMED CT Body Structures:
Codes describing anatomical locations. May include laterality.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Summary
|
true
|
To
Do
To Do
|
Is
this
approach
or
target
site?
RIM
mapping
inconsistent
with
ProcedureRequest
which
lists
target
site.
Recommend
calling
field
targetBodySite
or
targetSite.
Is this approach or target site? RIM mapping inconsistent with ProcedureRequest which lists target site. Recommend calling field targetBodySite or targetSite.
|
|
Procedure.reason[x]
|
|
Definition
|
The
reason
why
the
procedure
was
performed.
This
may
be
due
to
a
Condition,
may
be
coded
entity
of
some
type,
or
may
simply
be
present
as
text.
The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.
|
|
Control
|
0..1
|
|
Binding
|
Procedure
Reason
Codes:
A
code
that
identifies
the
reason
a
procedure
is
required.
(
Procedure Reason Codes:
A code that identifies the reason a procedure is required.
(
Example
)
|
|
Type
|
CodeableConcept
|
Reference
(
Condition
)
|
[x]
Note
[x] Note
|
See
Choice
of
Data
Types
for
further
information
about
how
to
use
[x]
See
Choice of Data Types
for further information about how to use [x]
|
|
Summary
|
true
|
|
Comments
|
e.g.
endoscopy
for
dilatation
and
biopsy,
combination
diagnosis
and
therapeutic.
e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.
|
|
Procedure.performer
|
|
Definition
|
Limited
to
'real'
people
rather
than
equipment.
Limited to 'real' people rather than equipment.
|
|
Control
|
0..*
|
|
Summary
|
true
|
|
Procedure.performer.actor
|
|
Definition
|
The
practitioner
who
was
involved
in
the
procedure.
The practitioner who was involved in the procedure.
|
|
Control
|
0..1
|
|
Type
|
Reference
(
Practitioner
|
|
Organization
|
|
Patient
|
|
RelatedPerson
)
|
|
Summary
|
true
|
|
Procedure.performer.role
|
|
Definition
|
For
example:
surgeon,
anaethetist,
endoscopist.
For example: surgeon, anaethetist, endoscopist.
|
|
Control
|
0..1
|
|
Binding
|
Procedure
Performer
Role
Codes:
A
code
that
identifies
the
role
of
a
performer
of
the
procedure.
(
Procedure Performer Role Codes:
A code that identifies the role of a performer of the procedure.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Summary
|
true
|
|
Procedure.performed[x]
|
|
Definition
|
The
date(time)/period
over
which
the
procedure
was
performed.
Allows
a
period
to
support
complex
procedures
that
span
more
than
one
date,
and
also
allows
for
the
length
of
the
procedure
to
be
captured.
The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.
|
|
Control
|
0..1
|
|
Type
|
dateTime
|
Period
|
[x]
Note
[x] Note
|
See
Choice
of
Data
Types
for
further
information
about
how
to
use
[x]
See
Choice of Data Types
for further information about how to use [x]
|
|
Summary
|
true
|
|
Procedure.encounter
|
|
Definition
|
The
encounter
during
which
the
procedure
was
performed.
The encounter during which the procedure was performed.
|
|
Control
|
0..1
|
|
Type
|
Reference
(
Encounter
)
|
|
Summary
|
true
|
|
Procedure.location
|
|
Definition
|
The
location
where
the
procedure
actually
happened.
E.g.
a
newborn
at
home,
a
tracheostomy
at
a
restaurant.
The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
|
|
Control
|
0..1
|
|
Type
|
Reference
(
Location
)
|
|
Requirements
|
Ties
a
procedure
to
where
the
records
are
likely
kept.
Ties a procedure to where the records are likely kept.
|
|
Summary
|
true
|
|
Procedure.outcome
|
|
Definition
|
The
outcome
of
the
procedure
-
did
it
resolve
reasons
for
the
procedure
being
performed?
The outcome of the procedure - did it resolve reasons for the procedure being performed?
|
|
Control
|
0..1
|
|
Binding
|
Procedure
Outcome
Codes
(SNOMED
CT):
An
outcome
of
a
procedure
-
whether
it
was
resolved
or
otherwise.
(
Procedure Outcome Codes (SNOMED CT):
An outcome of a procedure - whether it was resolved or otherwise.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Summary
|
true
|
|
Comments
|
If
outcome
contains
narrative
text
only,
it
can
be
captured
using
the
CodeableConcept.text.
If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
|
|
Procedure.report
|
|
Definition
|
This
could
be
a
histology
result,
pathology
report,
surgical
report,
etc..
This could be a histology result, pathology report, surgical report, etc..
|
|
Control
|
0..*
|
|
Type
|
Reference
(
DiagnosticReport
)
|
|
Comments
|
There
could
potentially
be
multiple
reports
-
e.g.
if
this
was
a
procedure
which
took
multiple
biopsies
resulting
in
a
number
of
anatomical
pathology
reports.
There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.
|
|
Procedure.complication
|
|
Definition
|
Any
complications
that
occurred
during
the
procedure,
or
in
the
immediate
post-performance
period.
These
are
generally
tracked
separately
from
the
notes,
which
will
typically
describe
the
procedure
itself
rather
than
any
'post
procedure'
issues.
Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.
|
|
Control
|
0..*
|
|
Binding
|
Condition/Problem/Diagnosis
Codes:
Codes
describing
complications
that
resulted
from
a
procedure.
(
Condition/Problem/Diagnosis Codes:
Codes describing complications that resulted from a procedure.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Comments
|
If
complications
are
only
expressed
by
the
narrative
text,
they
can
be
captured
using
the
CodeableConcept.text.
If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.
|
To
Do
To Do
|
Need
harmonization
proposal
for
new
ActRelationshipType
code.
Need harmonization proposal for new ActRelationshipType code.
|
|
Procedure.followUp
|
|
Definition
|
If
the
procedure
required
specific
follow
up
-
e.g.
removal
of
sutures.
The
followup
may
be
represented
as
a
simple
note,
or
could
potentially
be
more
complex
in
which
case
the
CarePlan
resource
can
be
used.
If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.
|
|
Control
|
0..*
|
|
Binding
|
Procedure
Follow
up
Codes
(SNOMED
CT):
Specific
follow
up
required
for
a
procedure
e.g.
removal
of
sutures.
(
Procedure Follow up Codes (SNOMED CT):
Specific follow up required for a procedure e.g. removal of sutures.
(
Example
)
|
|
Type
|
CodeableConcept
|
|
Procedure.request
|
|
Definition
|
A
reference
to
a
resource
that
contains
details
of
the
request
for
this
procedure.
A reference to a resource that contains details of the request for this procedure.
|
|
Control
|
0..1
|
|
Type
|
Reference
(
CarePlan
|
|
DiagnosticOrder
|
|
ProcedureRequest
|
|
ReferralRequest
)
|
|
Procedure.notes
|
|
Definition
|
Any
other
notes
about
the
procedure.
E.g.
the
operative
notes.
Any other notes about the procedure. E.g. the operative notes.
|
|
Control
|
0..*
|
|
Type
|
Annotation
|
|
Procedure.focalDevice
|
|
Definition
|
A
device
that
is
implanted,
removed
or
otherwise
manipulated
(calibration,
battery
replacement,
fitting
a
prosthesis,
attaching
a
wound-vac,
etc.)
as
a
focal
portion
of
the
Procedure.
A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.
|
|
Control
|
0..*
|
|
Procedure.focalDevice.action
|
|
Definition
|
The
kind
of
change
that
happened
to
the
device
during
the
procedure.
The kind of change that happened to the device during the procedure.
|
|
Control
|
0..1
|
|
Binding
|
Procedure
Device
Action
Codes:
A
kind
of
change
that
happened
to
the
device
during
the
procedure.
(
Procedure Device Action Codes:
A kind of change that happened to the device during the procedure.
(
Required
)
|
|
Type
|
CodeableConcept
|
|
Procedure.focalDevice.manipulated
|
|
Definition
|
The
device
that
was
manipulated
(changed)
during
the
procedure.
The device that was manipulated (changed) during the procedure.
|
|
Control
|
1..1
|
|
Type
|
Reference
(
Device
)
|
|
Procedure.used
|
|
Definition
|
Identifies
medications,
devices
and
any
other
substance
used
as
part
of
the
procedure.
Identifies medications, devices and any other substance used as part of the procedure.
|
|
Control
|
0..*
|
|
Type
|
Reference
(
Device
|
|
Medication
|
|
Substance
)
|
|
Requirements
|
Used
for
tracking
contamination,
etc.
Used for tracking contamination, etc.
|
|
Comments
|
For
devices
actually
implanted
or
removed,
use
Procedure.device.
For devices actually implanted or removed, use Procedure.device.
|
©
HL7.org
2011+.
FHIR
DSTU2
(v1.0.2-7202)
generated
on
Sat,
Oct
24,
2015
07:43+1100.
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