An action that is or was performed on or for a patient. This patient, practitioner, device, organization, or location. For example, this can be a physical intervention on a patient like an operation, or less invasive like long term services, counseling, or hypnotherapy. This can be a quality or safety inspection for a location, organization, or device. This can be an accreditation procedure on a practitioner for licensing.

Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Allows identification of the procedure as it is known by various participating systems and in a 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.

The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this 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 example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

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

The "unknown" code is not to be used to convey other statuses. The "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.

Captures the reason for the current state of the procedure.

This is generally only used for "exception" statuses such as "not-done", "suspended" or "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").

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

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

The person, animal On whom or group on which what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure.

Who is the target of the procedure when it is not the subject of record only. If focus is not present, then subject is the focus. If focus is present and the subject is one of the targets of the procedure, include subject as a focus as well. If focus is present and the subject is not included in focus, it implies that the procedure was only targeted on the focus. For example, when a caregiver is given education for a patient, the caregiver would be the focus and the procedure record is associated with the subject (e.g. patient). For example, use focus when recording the target of the education, training, or counseling is the parent or relative of a patient.

The Encounter during which this Procedure was 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.

Estimated or actual date, date-time, period, or age when the procedure was performed. did occur or is occurring. 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.

This indicates when the procedure actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this Procedure is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds.

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.

The date the occurrence of the procedure was first captured in the record regardless of Procedure.status (potentially after the occurrence of the event).

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

Individual who is making Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the procedure statement. source of the report.

Reported data may have different rules on editing and may be visually distinguished from primary data.

Limited to "real" people rather than equipment. Indicates who or what performed the procedure and how they were involved.

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

Allows disambiguation of the types of involvement of different performers.

The practitioner Indicates who was involved in or what performed the procedure.

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

The organization Organization the device or practitioner Patient, RelatedPerson, Device, CareTeam, and HealthcareService 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.

Organization, Patient, RelatedPerson, Device, CareTeam, and HealthcareService can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

The location where Time period during which the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. performer performed the procedure.

The coded reason why location where the procedure was performed. This may be actually happened. E.g. a coded entity of some type, or may simply be present as text. newborn at home, a tracheostomy at a restaurant.

The justification of coded reason or reference why the procedure was performed. This may be a coded entity of some type, be present as text, or be a reference to one of several resources that justify the procedure.

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 (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode Procedure.reason.concept when a code sufficiently describes the reason. Use Procedure.reasonReference Procedure.reason.reference 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 Procedure.reason, if both Procedure.reason.concept and Procedure.reason.reference are present, they are describing different reasons for the procedure. expected to be consistent with each other.

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 http://hl7.org/fhir/StructureDefinition/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.

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. Procedure.complicationDetail Element Id Procedure.complicationDetail Definition Any complications that occurred during the procedure, or in the immediate post-performance period. Cardinality 0..* Type Reference ( Condition ) Requirements This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. CodeableReference.concept.text.

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

Any other notes and comments about 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.

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. Procedure.focalDevice.manipulated.

Identifies coded items Other resources from the patient record that were used as part of may be relevant to the procedure. The information from these resources was either used to create the instance or is provided to help with its interpretation. This extension should not be used if more specific inline elements or extensions are available.