DSTU2

This page is part of the FHIR Specification (v0.0.82: (v1.0.2: DSTU 1). 2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

4.6 4.8 Resource Procedure - Content

Patient Care Work Group Maturity Level : 1 Compartments : Encounter , Patient , Practitioner , RelatedPerson

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

4.6.1 4.8.1 Scope and Usage

This resource is used to record the details of procedures performed on a patient. A procedure is an activity that is performed with or on a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, exercise, etc. Procedures may be performed by a healthcare professional, a friend or relative or in some cases by the patient themselves.

This resource provides summary information about the occurrence of the procedure and exclude things is not intended to provide real-time snapshots of a procedure as it unfolds, though for which there are specific resources, long-running procedures such as immunizations, psychotherapy, it could represent summary level information about overall progress. The creation of a resource to support detailed real-time procedure information awaits the identification of a specific implementation use-case to share such information.

4.8.2 Boundaries and Relationships

The Procedure resource should not be used to capture an event if a more specific resource already exists - i.e. immunizations , drug administrations. administrations and communications . The boundary between determining whether an action is considered to be training or counseling (and thus a procedure) as opposed to a Communication is based on whether there's a specific intent to change the mind-set of the patient. Mere disclosure of information would be considered a Communication. A process that involves verification of the patient's comprehension or to change the patient's mental state would be a Procedure.

Note that many diagnostic processes are procedures that generate observations Observations and reports. DiagnosticReports . In many cases, the existence such an observation does not require an explicit representation of the procedure is assumed, used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the procedure resource is used to describe the activity.

Some diagnostic procedures may not have a Procedure record.  The Procedure record is only necessary when there is a need to capture information about the physical intervention that was performed to capture the diagnostic information (e.g. anesthetic, incision, scope size, etc.)

This resource is referenced by ClinicalImpression , Encounter and ImagingStudy

4.6.2 4.8.3 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
.. Procedure I DomainResource An action that is being or was performed on a patient
Reason not performed is only permitted if notPerformed indicator is true
... identifier Σ 0..* Identifier External Identifiers for this procedure
... subject Σ 1..1 Reference ( Patient | Group ) Who the procedure was performed on
... status ?! Σ 1..1 code in-progress | aborted | completed | entered-in-error
ProcedureStatus ( Required )
... category Σ 0..1 CodeableConcept Classification of the procedure
Procedure Category Codes (SNOMED CT) ( Example )
... code Σ 1..1 CodeableConcept Identification of the procedure
Procedure Codes (SNOMED CT) ( Example )
... notPerformed ?! 0..1 boolean True if procedure was not performed as scheduled
... reasonNotPerformed I 0..* CodeableConcept Reason procedure was not performed
Procedure Not Performed Reason (SNOMED-CT) ( Example )
... bodySite Σ 0..* CodeableConcept Target body sites
SNOMED CT Body Structures ( Example )
... reason[x] Σ 0..1 Reason procedure performed
Procedure Reason Codes ( Example )
.... reasonCodeableConcept CodeableConcept
.... reasonReference Reference ( Condition )
... performer Σ 0..* BackboneElement The people who performed the procedure
.... actor Σ 0..1 Reference ( Practitioner | Organization | Patient | RelatedPerson ) The reference to the practitioner
.... role Σ 0..1 CodeableConcept The role the actor was in
Procedure Performer Role Codes ( Example )
... performed[x] Σ 0..1 Date/Period the procedure was performed
.... performedDateTime dateTime
.... performedPeriod Period
... encounter Σ 0..1 Reference ( Encounter ) The encounter associated with the procedure
... location Σ 0..1 Reference ( Location ) Where the procedure happened
... outcome Σ 0..1 CodeableConcept The result of procedure
Procedure Outcome Codes (SNOMED CT) ( Example )
... report 0..* Reference ( DiagnosticReport ) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Condition/Problem/Diagnosis Codes ( Example )
... followUp 0..* CodeableConcept Instructions for follow up
Procedure Follow up Codes (SNOMED CT) ( Example )
... request 0..1 Reference ( CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequest ) A request for this procedure
... notes 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Device changed in procedure
.... action 0..1 CodeableConcept Kind of change to device
Procedure Device Action Codes ( Required )
.... manipulated 1..1 Reference ( Device ) Device that was changed
... used 0..* Reference ( Device | Medication | Substance ) Items used during procedure

doco Documentation for this format

UML Diagram

Procedure ( Resource DomainResource ) This records identifiers associated with this procedure that are defined by business processed and/ or 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) identifier : Identifier 0..* [0..*] The person person, animal or group on whom which the procedure was performed subject : Resource Reference ( [1..1] « Patient ) 1..1 | Group » A code specifying the state of the procedure. Generally this will be in-progress or completed state (this element modifies the meaning of other elements) status : code [1..1] « A code specifying the state of the procedure. (Strength=Required) ProcedureStatus ! » A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure") category : CodeableConcept [0..1] « A code that classifies a procedure for searching, sorting and display purposes. (Strength=Example) Procedure Category Codes (SNO... ?? » The specific procedure that is performed. Use text if the exact nature of the procedure can't cannot be coded (e.g. "Laparoscopic Appendectomy") type code : CodeableConcept 1..1 [1..1] « A code to identify a specific procedure . (Strength=Example) Procedure Codes (SNOMED CT) ?? » Set this to true if the record is saying that the procedure was NOT performed (this element modifies the meaning of other elements) notPerformed : boolean [0..1] A code indicating why the procedure was not performed reasonNotPerformed : CodeableConcept [0..*] « A code that identifies the reason a procedure was not performed. (Strength=Example) Procedure Not Performed Reaso... ?? » Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion bodySite : CodeableConcept 0..* [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example) SNOMED CT Body Structures ?? » 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 indication reason[x] : Type [0..1] « CodeableConcept 0..* | Reference ( Condition ); A code that identifies the reason a procedure is required. (Strength=Example) Procedure Reason ?? » The dates date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more that than one date, and also allows for the length of the procedure to be captured date performed[x] : Type [0..1] « dateTime | Period 0..1 » The encounter during which the procedure was performed encounter : Resource Reference ( [0..1] « Encounter ) 0..1 » What was The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant location : Reference [0..1] « Location » The outcome of the procedure - did it resolve reasons why for the procedure was being performed? outcome : string CodeableConcept 0..1 [0..1] « An outcome of a procedure - whether it was resolved or otherwise. (Strength=Example) Procedure Outcome Codes (SNOM... ?? » This could be a histology result. There could potentially be multiple reports - e.g. if this was a procedure that made multiple biopsies result, pathology report, surgical report, etc. report : Resource Reference ( [0..*] « DiagnosticReport ) 0..* » Any complications that occurred during the procedure, or in the immediate post-operative post-performance period. These are generally tracked separately from the notes, which typically will typically describe the procedure itself rather than any 'post procedure' issues complication : CodeableConcept 0..* [0..*] « Codes describing complications that resulted from a procedure. (Strength=Example) Condition/Problem/Diagnosis ?? » If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or potentially could potentially be more complex in which case the CarePlan resource can be used followUp : string CodeableConcept 0..1 [0..*] « Specific follow up required for a procedure e.g. removal of sutures. (Strength=Example) Procedure Follow up Codes (SN... ?? » A reference to a resource that contains details of the request for this procedure request : Reference [0..1] « CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequest » Any other notes about the procedure - e.g. procedure. E.g. the operative notes notes : string Annotation 0..1 [0..*] Identifies medications, devices and any other substance used as part of the procedure used : Reference [0..*] « Device | Medication | Substance » Performer The practitioner who was involved in the procedure person actor : Resource Reference ( [0..1] « Practitioner ) 0..1 | Organization | Patient | RelatedPerson » E.g. For example: surgeon, anaethetist, endoscopist role : CodeableConcept [0..1] « A code that identifies the role of a performer of the procedure. (Strength=Example) Procedure Performer Role ?? » FocalDevice The kind of change that happened to the device during the procedure action : CodeableConcept [0..1] « A kind of change that happened to the device during the procedure. (Strength=Required) Procedure Device Action ! » The device that was manipulated (changed) during the procedure manipulated : Reference [1..1] « Device » Limited to 'real' people rather than equipment performer [0..*] 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 focalDevice [0..*]

XML Template 


<Procedure xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Identifiers for this procedure --></identifier>
 <subject><!-- 1..1 Reference(Patient|Group) Who the procedure was performed on --></subject>
 <status value="[code]"/><!-- 1..1 in-progress | aborted | completed | entered-in-error -->
 <category><!-- 0..1 CodeableConcept Classification of the procedure --></category>
 <code><!-- 1..1 CodeableConcept Identification of the procedure --></code>
 <notPerformed value="[boolean]"/><!-- 0..1 True if procedure was not performed as scheduled -->
 <reasonNotPerformed><!-- ?? 0..* CodeableConcept Reason procedure was not performed --></reasonNotPerformed>
 <bodySite><!-- 0..* CodeableConcept Target body sites --></bodySite>
 <reason[x]><!-- 0..1 CodeableConcept|Reference(Condition) Reason procedure performed --></reason[x]>
 <performer>  <!-- 0..* The people who performed the procedure -->
  <actor><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) The reference to the practitioner --></actor>
  <role><!-- 0..1 CodeableConcept The role the actor was in --></role>
 </performer>
 <performed[x]><!-- 0..1 dateTime|Period Date/Period the procedure was performed --></performed[x]>
 <encounter><!-- 0..1 Reference(Encounter) The encounter associated with the procedure --></encounter>
 <location><!-- 0..1 Reference(Location) Where the procedure happened --></location>
 <outcome><!-- 0..1 CodeableConcept The result of procedure --></outcome>
 <report><!-- 0..* Reference(DiagnosticReport) Any report resulting from the procedure --></report>
 <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication>
 <followUp><!-- 0..* CodeableConcept Instructions for follow up --></followUp>
 <request><!-- 0..1 Reference(CarePlan|DiagnosticOrder|ProcedureRequest|
   ReferralRequest) A request for this procedure --></request>

 <notes><!-- 0..* Annotation Additional information about the procedure --></notes>
 <focalDevice>  <!-- 0..* Device changed in procedure -->
  <action><!-- 0..1 CodeableConcept Kind of change to device --></action>
  <manipulated><!-- 1..1 Reference(Device) Device that was changed --></manipulated>
 </focalDevice>
 <used><!-- 0..* Reference(Device|Medication|Substance) Items used during procedure --></used>
</Procedure>

JSON Template 


{doco
  "resourceType" : "Procedure",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Identifiers for this procedure
  "subject" : { Reference(Patient|Group) }, // R!  Who the procedure was performed on
  "status" : "<code>", // R!  in-progress | aborted | completed | entered-in-error
  "category" : { CodeableConcept }, // Classification of the procedure
  "code" : { CodeableConcept }, // R!  Identification of the procedure
  "notPerformed" : <boolean>, // True if procedure was not performed as scheduled
  "reasonNotPerformed" : [{ CodeableConcept }], // C? Reason procedure was not performed
  "bodySite" : [{ CodeableConcept }], // Target body sites
  // reason[x]: Reason procedure performed. One of these 2:

  "reasonCodeableConcept" : { CodeableConcept },
  "reasonReference" : { Reference(Condition) },
  "performer" : [{ // The people who performed the procedure
    "actor" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }, // The reference to the practitioner
    "role" : { CodeableConcept } // The role the actor was in
  }],
  // performed[x]: Date/Period the procedure was performed. One of these 2:

  "performedDateTime" : "<dateTime>",
  "performedPeriod" : { Period },
  "encounter" : { Reference(Encounter) }, // The encounter associated with the procedure
  "location" : { Reference(Location) }, // Where the procedure happened
  "outcome" : { CodeableConcept }, // The result of procedure
  "report" : [{ Reference(DiagnosticReport) }], // Any report resulting from the procedure
  "complication" : [{ CodeableConcept }], // Complication following the procedure
  "followUp" : [{ CodeableConcept }], // Instructions for follow up
  "request" : { Reference(CarePlan|DiagnosticOrder|ProcedureRequest|
   ReferralRequest) }, // A request for this procedure

  "notes" : [{ Annotation }], // Additional information about the procedure
  "focalDevice" : [{ // Device changed in procedure
    "action" : { CodeableConcept }, // Kind of change to device
    "manipulated" : { Reference(Device) } // R!  Device that was changed
  }],
  "used" : [{ Reference(Device|Medication|Substance) }] // Items used during procedure
}

Structure

Name Flags Card. Type Description & Constraints doco
.. Procedure I DomainResource An action that is being or was performed on a patient
Reason not performed is only permitted if notPerformed indicator is true
... identifier Σ 0..* Identifier External Identifiers for this procedure
... subject Σ 1..1 Reference ( Patient | Group ) Who the procedure was performed on
... status ?! Σ 1..1 code in-progress | aborted | completed | entered-in-error
ProcedureStatus ( Required )
... category Σ 0..1 CodeableConcept Classification of the procedure
Procedure Category Codes (SNOMED CT) ( Example )
... code Σ 1..1 CodeableConcept Identification of the procedure
Procedure Codes (SNOMED CT) ( Example )
... notPerformed ?! 0..1 boolean True if procedure was not performed as scheduled
... reasonNotPerformed I 0..* CodeableConcept Reason procedure was not performed
Procedure Not Performed Reason (SNOMED-CT) ( Example )
... bodySite Σ 0..* CodeableConcept Target body sites
SNOMED CT Body Structures ( Example )
... reason[x] Σ 0..1 Reason procedure performed
Procedure Reason Codes ( Example )
.... reasonCodeableConcept CodeableConcept
.... reasonReference Reference ( Condition )
... performer Σ 0..* BackboneElement The people who performed the procedure
.... actor Σ 0..1 Reference ( Practitioner | Organization | Patient | RelatedPerson ) The reference to the practitioner
.... role Σ 0..1 CodeableConcept The role the actor was in
Procedure Performer Role Codes ( Example )
... performed[x] Σ 0..1 Date/Period the procedure was performed
.... performedDateTime dateTime
.... performedPeriod Period
... encounter Σ 0..1 Reference ( Encounter ) The encounter associated with the procedure
... location Σ 0..1 Reference ( Location ) Where the procedure happened
... outcome Σ 0..1 CodeableConcept The result of procedure
Procedure Outcome Codes (SNOMED CT) ( Example )
... report 0..* Reference ( DiagnosticReport ) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Condition/Problem/Diagnosis Codes ( Example )
... followUp 0..* CodeableConcept Instructions for follow up
Procedure Follow up Codes (SNOMED CT) ( Example )
... request 0..1 Reference ( CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequest ) A request for this procedure
... notes 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Device changed in procedure
.... action 0..1 CodeableConcept Kind of change to device
Procedure Device Action Codes ( Required )
.... manipulated 1..1 Reference ( Device ) Device that was changed
... used 0..* Reference ( Device | Medication | Substance ) Items used during procedure

doco Documentation for this format

UML Diagram

Procedure ( DomainResource ) RelatedItem 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) identifier : Identifier [0..*] The nature person, animal or group on which the procedure was performed subject : Reference [1..1] « Patient | Group » A code specifying the state of the relationship procedure. Generally this will be in-progress or completed state (this element modifies the meaning of other elements) type status : code 0..1 << [1..1] « A code specifying the state of the procedure. (Strength=Required) ProcedureStatus ! » A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure") category : CodeableConcept [0..1] « A code that classifies a procedure for searching, sorting and display purposes. (Strength=Example) Procedure Category Codes (SNO... ?? » The specific procedure that is performed. Use text if the exact nature of the relationship with procedure cannot be coded (e.g. "Laparoscopic Appendectomy") code : CodeableConcept [1..1] « A code to identify a specific procedure . (Strength=Example) Procedure Codes (SNOMED CT) ?? » Set this to true if the record is saying that the procedure was NOT performed (this element modifies the meaning of other elements) ProcedureRelationshipType notPerformed >> : boolean [0..1] The related item A code indicating why the procedure was not performed reasonNotPerformed : CodeableConcept [0..*] « A code that identifies the reason a procedure was not performed. (Strength=Example) Procedure Not Performed Reaso... ?? » Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a procedure lesion target bodySite : Resource CodeableConcept ( AdverseReaction [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example) SNOMED CT Body Structures | ?? » AllergyIntolerance 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 reason[x] | CarePlan : Type [0..1] « CodeableConcept | Reference ( Condition | ); A code that identifies the reason a procedure is required. (Strength=Example) DeviceObservationReport Procedure Reason ?? » 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 performed[x] : Type [0..1] « dateTime | Period » The encounter during which the procedure was performed encounter : Reference [0..1] « Encounter » The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant location : Reference [0..1] « Location » The outcome of the procedure - did it resolve reasons for the procedure being performed? outcome : CodeableConcept [0..1] « An outcome of a procedure - whether it was resolved or otherwise. (Strength=Example) Procedure Outcome Codes (SNOM... ?? » This could be a histology result, pathology report, surgical report, etc. report : Reference [0..*] « DiagnosticReport | » FamilyHistory 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 complication | ImagingStudy : CodeableConcept | Immunization [0..*] « Codes describing complications that resulted from a procedure. (Strength=Example) Condition/Problem/Diagnosis | ?? » ImmunizationRecommendation 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 followUp | : CodeableConcept [0..*] « Specific follow up required for a procedure e.g. removal of sutures. (Strength=Example) Procedure Follow up Codes (SN... ?? » MedicationAdministration A reference to a resource that contains details of the request for this procedure request : Reference [0..1] « CarePlan | DiagnosticOrder | MedicationDispense ProcedureRequest | ReferralRequest » MedicationPrescription Any other notes about the procedure. E.g. the operative notes notes : Annotation [0..*] Identifies medications, devices and any other substance used as part of the procedure used : Reference [0..*] « Device | Medication | Substance » MedicationStatement Performer The practitioner who was involved in the procedure actor : Reference [0..1] « Practitioner | Observation Organization | Patient | RelatedPerson » For example: surgeon, anaethetist, endoscopist role : CodeableConcept [0..1] « A code that identifies the role of a performer of the procedure. (Strength=Example) Procedure Performer Role ) 0..1 ?? » FocalDevice The kind of change that happened to the device during the procedure action : CodeableConcept [0..1] « A kind of change that happened to the device during the procedure. (Strength=Required) Procedure Device Action ! » The device that was manipulated (changed) during the procedure manipulated : Reference [1..1] « Device » Limited to 'real' people rather than equipment performer 0..* [0..*] Procedures may be related to other items such as procedures A device that is implanted, removed or medications. For example treating wound dehiscence following otherwise manipulated (calibration, battery replacement, fitting a previous procedure prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure relatedItem focalDevice 0..* [0..*] This resource is referenced by CarePlan and Condition

XML Template

< <!-- from --> <</identifier> <</subject> <</type> <</bodySite> <</indication> < <</person> <</role> 
<Procedure xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Identifiers for this procedure --></identifier>
 <subject><!-- 1..1 Reference(Patient|Group) Who the procedure was performed on --></subject>
 <status value="[code]"/><!-- 1..1 in-progress | aborted | completed | entered-in-error -->
 <category><!-- 0..1 CodeableConcept Classification of the procedure --></category>
 <code><!-- 1..1 CodeableConcept Identification of the procedure --></code>
 <notPerformed value="[boolean]"/><!-- 0..1 True if procedure was not performed as scheduled -->
 <reasonNotPerformed><!-- ?? 0..* CodeableConcept Reason procedure was not performed --></reasonNotPerformed>
 <bodySite><!-- 0..* CodeableConcept Target body sites --></bodySite>
 <reason[x]><!-- 0..1 CodeableConcept|Reference(Condition) Reason procedure performed --></reason[x]>
 <performer>  <!-- 0..* The people who performed the procedure -->
  <actor><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) The reference to the practitioner --></actor>
  <role><!-- 0..1 CodeableConcept The role the actor was in --></role>

 </performer>
 <</date>
 <</encounter>
 <
 <</report>
 <</complication>
 <
 <
  <
  <|
    |
    |
    |
    </target>
 </relatedItem>
 <

 <performed[x]><!-- 0..1 dateTime|Period Date/Period the procedure was performed --></performed[x]>
 <encounter><!-- 0..1 Reference(Encounter) The encounter associated with the procedure --></encounter>
 <location><!-- 0..1 Reference(Location) Where the procedure happened --></location>
 <outcome><!-- 0..1 CodeableConcept The result of procedure --></outcome>
 <report><!-- 0..* Reference(DiagnosticReport) Any report resulting from the procedure --></report>
 <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication>
 <followUp><!-- 0..* CodeableConcept Instructions for follow up --></followUp>
 <request><!-- 0..1 Reference(CarePlan|DiagnosticOrder|ProcedureRequest|
   ReferralRequest) A request for this procedure --></request>

 <notes><!-- 0..* Annotation Additional information about the procedure --></notes>
 <focalDevice>  <!-- 0..* Device changed in procedure -->
  <action><!-- 0..1 CodeableConcept Kind of change to device --></action>
  <manipulated><!-- 1..1 Reference(Device) Device that was changed --></manipulated>
 </focalDevice>
 <used><!-- 0..* Reference(Device|Medication|Substance) Items used during procedure --></used>

</Procedure>

JSON Template 


{doco
  "resourceType" : "Procedure",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Identifiers for this procedure
  "subject" : { Reference(Patient|Group) }, // R!  Who the procedure was performed on
  "status" : "<code>", // R!  in-progress | aborted | completed | entered-in-error
  "category" : { CodeableConcept }, // Classification of the procedure
  "code" : { CodeableConcept }, // R!  Identification of the procedure
  "notPerformed" : <boolean>, // True if procedure was not performed as scheduled
  "reasonNotPerformed" : [{ CodeableConcept }], // C? Reason procedure was not performed
  "bodySite" : [{ CodeableConcept }], // Target body sites
  // reason[x]: Reason procedure performed. One of these 2:

  "reasonCodeableConcept" : { CodeableConcept },
  "reasonReference" : { Reference(Condition) },
  "performer" : [{ // The people who performed the procedure
    "actor" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }, // The reference to the practitioner
    "role" : { CodeableConcept } // The role the actor was in
  }],
  // performed[x]: Date/Period the procedure was performed. One of these 2:

  "performedDateTime" : "<dateTime>",
  "performedPeriod" : { Period },
  "encounter" : { Reference(Encounter) }, // The encounter associated with the procedure
  "location" : { Reference(Location) }, // Where the procedure happened
  "outcome" : { CodeableConcept }, // The result of procedure
  "report" : [{ Reference(DiagnosticReport) }], // Any report resulting from the procedure
  "complication" : [{ CodeableConcept }], // Complication following the procedure
  "followUp" : [{ CodeableConcept }], // Instructions for follow up
  "request" : { Reference(CarePlan|DiagnosticOrder|ProcedureRequest|
   ReferralRequest) }, // A request for this procedure

  "notes" : [{ Annotation }], // Additional information about the procedure
  "focalDevice" : [{ // Device changed in procedure
    "action" : { CodeableConcept }, // Kind of change to device
    "manipulated" : { Reference(Device) } // R!  Device that was changed
  }],
  "used" : [{ Reference(Device|Medication|Substance) }] // Items used during procedure
}

 

Alternate definitions: Schema / Schematron , Resource Profile ( XML , JSON ), Questionnaire

4.6.2.1 4.8.3.1 Terminology Bindings

Procedure.relatedItem.type
Path Definition Type Reference
Procedure.status The nature A code specifying the state of the relationship with this procedure. Required ProcedureStatus
Procedure.category A code that classifies a procedure for searching, sorting and display purposes. Fixed Example http://hl7.org/fhir/procedure-relationship-type Procedure Category Codes (SNOMED CT)
Procedure.code A code to identify a specific procedure . Example Procedure Codes (SNOMED CT)
Procedure.reasonNotPerformed A code that identifies the reason a procedure was not performed. Example Procedure Not Performed Reason (SNOMED-CT)
Procedure.bodySite Codes describing anatomical locations. May include laterality. Example SNOMED CT Body Structures
Procedure.reason[x] A code that identifies the reason a procedure is required. Example Procedure Reason Codes
Procedure.performer.role A code that identifies the role of a performer of the procedure. Example Procedure Performer Role Codes
Procedure.outcome An outcome of a procedure - whether it was resolved or otherwise. Example Procedure Outcome Codes (SNOMED CT)
Procedure.complication Codes describing complications that resulted from a procedure. Example Condition/Problem/Diagnosis Codes
Procedure.followUp Specific follow up required for a procedure e.g. removal of sutures. Example Procedure Follow up Codes (SNOMED CT)
Procedure.focalDevice.action A kind of change that happened to the device during the procedure. Required Procedure Device Action Codes

4.6.3 4.8.3.2 Constraints

  • pro-1 : Reason not performed is only permitted if notPerformed indicator is true (xpath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true() )

4.8.3.3 Use of Procedure properties

Many of the elements of Procedure have inherent relationships and may actually all be conveyed by the Procedure.code or in the text element of the Procedure.code property. I.e. You may be able to infer category, bodySite and even indication. Whether these other properties will be populated may vary by implementation.

Care should be taken to avoid nonsensical combinations/statements; e.g. "name=amputation, bodySite=heart"

4.8.3.4 Use of Procedure.used

For devices, these are devices that are incidental to / or used to perform the procedure - scalpels, gauze, endoscopes, etc. Devices that are the focus of the procedure should appear in Procedure.device instead.

4.8.4 Search Parameters

Search parameters for this resource. The standard common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Paths
_id code token A code to identify a procedure Procedure.code
date date Date/Period the procedure was performed Procedure.performed[x]
encounter reference The logical resource id encounter associated with the resource (must be supported by all servers) procedure Procedure.encounter
( Encounter )
_language identifier token The language of the resource A unique identifier for a procedure Procedure.identifier
date location date reference The date Where the procedure was performed on happened Procedure.date Procedure.location
( Location )
subject patient reference The identity of Search by subject - a patient to list procedures for Procedure.subject
( Patient )
type performer token reference Type of procedure The reference to the practitioner Procedure.type Procedure.performer.actor
( Patient , Organization , Practitioner , RelatedPerson )
subject reference Search by subject Procedure.subject
( Patient , Group )
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