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4.8.6 4.10.6 Resource Procedure - Detailed Descriptions Resource Procedure - Detailed Descriptions Detailed Descriptions for the elements in the Procedure resource.

Detailed Descriptions for the elements in the Procedure resource.

© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100. Links: Search
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.