An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like counseling long term services, counseling, or hypnotherapy.

This records Business identifiers associated with assigned to this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the performer or other systems which remain constant as the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). updated and is propagated from server to server.

Need to allow connection to Allows identification of the procedure as it is known by various participating systems and in a wider workflow. way that remains consistent across servers.

This is a business identifier, not a resource identifier (see discussion ). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

A The URL pointing to a FHIR-defined protocol, guideline, orderset order set or other definition that was is adhered to in whole or in part by this procedure. Procedure.

The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

A reference to a resource that contains details of the request for this procedure.

A larger event of which this particular procedure is a component or step.

The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, example, the anesthesia related medicationAdministration MedicationAdministration is part of the procedure. surgical Procedure (MedicationAdministration.partOf = Procedure). For an IV medication administration, example, the procedure to insert the IV port for an IV medication administration is part of the medication administration. administration (Procedure.partOf = MedicationAdministration).

A code specifying the state of the procedure. Generally Generally, this will be the in-progress or completed state.

The unknown "unknown" code is not to be used to convey other statuses. The unknown "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

If true, it means Captures the procedure did not occur as described. Typically it would be accompanied by attributes describing reason for the type current state of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome. This element is labeled as a modifier because it indicates that a procedure didn't happen. Procedure.notDoneReason Definition A code indicating why the procedure was not performed. procedure.

This is generally only permitted if notDone indicator is true ( expression : notDoneReason.empty() or notDone = true, xpath: not(exists(f:notDoneReason)) used for "exception" statuses such as "not-done", "suspended" or f:notDone/@value=true()) "aborted". The reason for performing the event at all is captured in reasonCode, not here.

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). "Surgical Procedure").

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). "Laparoscopic Appendectomy").

0..1 to account for primarily narrative only resources.

The person, animal or group on which the procedure was performed.

The encounter Encounter during which the procedure this Procedure was performed. created or performed or to which the creation of this record is tightly associated.

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

The date(time)/period over which Estimated or actual date, date-time, period, or age when 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.

Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Individual who recorded the record and takes responsibility for its content.

Individual who is making the procedure statement.

Limited to 'real' "real" people rather than equipment.

Distinguishes the type of involvement of the performer in the procedure. For example: example, surgeon, anaethetist, anaesthetist, endoscopist.

Allows disambiguation of the types of involvement of different performers.

The practitioner who was involved in the procedure.

A reference to Device supports use cases, such as pacemakers.

The organization the device or practitioner was acting on behalf of.

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Ties a procedure to where the records are likely kept.

The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

The condition that is the reason justification of why the procedure was performed.

e.g. It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy, biopsy (a combination diagnosis of diagnostic and therapeutic. therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure .

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

This could be a histology result, pathology report, surgical report, etc.. etc.

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.

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.

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Any complications that occurred during the procedure, or in the immediate post-performance period.

This is used to document a condition that is that is a result of the procedure, not the condition that was that was the reason for the procedure. the procedure.

If the procedure required specific follow up - e.g. removal of sutures. The followup follow up may be represented as a simple note, note or could potentially be more complex complex, in which case the CarePlan resource can be used.

Any other notes and comments about the procedure. E.g. the operative notes.

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.

The kind of change that happened to the device during the procedure.

The device that was manipulated (changed) during the procedure.

Identifies medications, devices and any other substance used as part of the procedure.

Used for tracking contamination, etc.

For devices actually implanted or removed, use Procedure.device.

Identifies coded items that were used as part of the procedure.

For devices actually implanted or removed, use Procedure.device.