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.

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).

Need to allow connection to a wider workflow.

The person, animal A protocol, guideline, orderset or group on which the procedure other definition that was performed. adhered to in whole or in part by this procedure.

A code specifying the state reference to a resource that contains details of the procedure. Generally request for this will be in-progress or completed state. procedure.

A code that classifies the larger event of which this particular procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). is a component or step.

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

The specific procedure that is performed. Use text if A code specifying the exact nature state of the procedure cannot procedure. Generally this will be coded (e.g. "Laparoscopic Appendectomy"). 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.

Set this to true if the record is saying that the procedure was NOT performed.

If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type 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.

A code indicating why the procedure was not performed.

Detailed A code that classifies the procedure for searching, sorting and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. display purposes (e.g. "Surgical Procedure").

The reason why the specific procedure was that is performed. This may be due to a Condition, may be coded entity Use text if the exact nature of some type, or may simply the procedure cannot be present as text. coded (e.g. "Laparoscopic Appendectomy").

0..1 to use [x] account for primarily narrative only resources.

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. The person, animal or group on which the procedure was performed.

Limited to 'real' people rather than equipment. The encounter during which the procedure was performed.

The practitioner who date(time)/period over which the procedure was involved in performed. Allows a period to support complex procedures that span more than one date, and also allows for the procedure. length of the procedure to be captured.

Limited to 'real' people rather than equipment.

For example: surgeon, anaethetist, endoscopist.

The date(time)/period over which the procedure practitioner who was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of involved in the procedure to be captured. procedure.

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

The encounter during which organization the procedure device or practitioner was performed. 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 coded entity of some type, or may simply be present as text.

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

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.

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

The outcome of the procedure - did it resolve 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.

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

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

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.

Any other notes 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.