Canadian Baseline
1.1.0 - CI Build
Canadian Baseline, published by HL7 Canada - FHIR Implementation Work Group. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-Canada/ca-baseline/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-procedure | Version: 1.1.0 | |||
Draft as of 2020-07-21 | Computable Name: ProcedureProfile |
Proposed constraints and extensions on the Procedure Resource
This profile is seeking broader community and implementer feedback.
The cardinality on procedure.performed[x] has been constrained to 1..1. While this did not cause any Due Diligence Review Issues with IPS or US Core, we are seeking feedback from additional implementers on whether this cardinality restriction poses problems for their FHIR implementations.
This profile also socializes an example of a subset of SNOMED CT codes for procedures that is made available through the Infoway Terminology Gateway: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode. This extensional value set was developed after initial review of the profiles but has been added in. We are seeking community feedback as to whether this subset is in use today by Canadian implementers or whether or not we should point to the larger value set of SNOMED CT codes contained in the IPS Value Set.
Feedback can be provided using the Simplifier issue log for this profile.
This profile sets minimum expectations for the Procedure resource to record, search and fetch current or historical procedures performed on or for a patient. It identifies which elements and value sets SHALL be present in the resource when using this profile.
This profile defines localization concepts for use in an Canadian context.
All elements or attributes defined in FHIR have cardinality as part of their definition - a minimum number of required appearances and a maximum number.
Most elements in FHIR specification have a minimum cardinality of 0, which means that they may be missing from a resource when it is exchanged between systems.
Required elements:
Some elements are labeled as MustSupport meaning that implementations that produce or consume resources SHALL provide "support" for the element in some meaningful way (see Must Support definition).
Following elements are marked as Must Support in the Procedure profile to aid record matching in databases with many pediatric records.
Must Support elements:
This Procedure profile is used to provide summary information about the occurrence of current or historical procedures performed on or for a patient, and is not intended to provide real-time snapshots of a procedure as it unfolds. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise and so on.
A slice for absentOrUnknownProcedure comes from the IPS-UV specification and has been socialized in the profile as a way to represent a standard set of codes for identifying absent or unknown procedures. While the profile expects that a procedure.code be present (cardinality of 1..1) the use of the slice is entirely optional.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
Path | Conformance | ValueSet | URI |
Procedure.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/interventioncodehttps://fhir.infoway-inforoute.ca/ValueSet/interventioncode | |
Procedure.code:absentOrUnknownProcedure | required | http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ipshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | Procedure | Procedure Profile | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
partOf | Σ | 0..* | Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile) | Part of referenced event |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
Slices for code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers. |
code:absentOrUnknownProcedure | Σ | 0..1 | CodeableConcept | Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures |
subject | SΣ | 1..1 | Reference(Patient Profile) | Who the procedure was performed on |
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of |
performed[x] | SΣ | 1..1 | When the procedure was performed | |
performed[x]All Types | Content/Rules for all Types | |||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
data-absent-reason | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) | |
performedDateTime | dateTime | |||
performedPeriod | Period | |||
performedString | string | |||
performedAge | Age | |||
performedRange | Range | |||
recorder | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Who recorded the procedure |
asserter | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Person who asserts this procedure |
location | Σ | 0..1 | Reference(Location Profile) | Where the procedure happened |
reasonReference | Σ | 0..* | Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document) | The justification that the procedure was performed |
complicationDetail | 0..* | Reference(Condition Profile) | A condition that is a result of the procedure | |
usedReference | 0..* | Reference(Device Profile (Implantable) | Medication Profile | Substance) | Items used during procedure | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/interventioncodehttps://fhir.infoway-inforoute.ca/ValueSet/interventioncode | |
Procedure.code:absentOrUnknownProcedure | required | http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ipshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | 0..* | Procedure | Procedure Profile | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
partOf | Σ | 0..* | Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
Slices for code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers. | ||||
code:absentOrUnknownProcedure | Σ | 0..1 | CodeableConcept | Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures | ||||
subject | SΣ | 1..1 | Reference(Patient Profile) | Who the procedure was performed on | ||||
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of | ||||
performed[x] | SΣ | 1..1 | When the procedure was performed | |||||
performed[x]All Types | Content/Rules for all Types | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
data-absent-reason | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) | |||||
performedDateTime | dateTime | |||||||
performedPeriod | Period | |||||||
performedString | string | |||||||
performedAge | Age | |||||||
performedRange | Range | |||||||
recorder | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Who recorded the procedure | ||||
asserter | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Person who asserts this procedure | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
actor | Σ | 1..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile | RelatedPerson | Device Profile (Implantable)) | The reference to the practitioner | ||||
onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
location | Σ | 0..1 | Reference(Location Profile) | Where the procedure happened | ||||
reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
reasonReference | Σ | 0..* | Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document) | The justification that the procedure was performed | ||||
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
complicationDetail | 0..* | Reference(Condition Profile) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
note | 0..* | Annotation | Additional information about the procedure | |||||
focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
usedReference | 0..* | Reference(Device Profile (Implantable) | Medication Profile | Substance) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | ||||
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/interventioncodehttps://fhir.infoway-inforoute.ca/ValueSet/interventioncode | ||||
Procedure.code:absentOrUnknownProcedure | required | http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ipshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips | ||||
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Procedure
Summary
Mandatory: 3 elements
Must-Support: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Procedure
Path | Conformance | ValueSet | URI |
Procedure.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/interventioncodehttps://fhir.infoway-inforoute.ca/ValueSet/interventioncode | |
Procedure.code:absentOrUnknownProcedure | required | http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ipshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | Procedure | Procedure Profile | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
partOf | Σ | 0..* | Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile) | Part of referenced event |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
Slices for code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers. |
code:absentOrUnknownProcedure | Σ | 0..1 | CodeableConcept | Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures |
subject | SΣ | 1..1 | Reference(Patient Profile) | Who the procedure was performed on |
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of |
performed[x] | SΣ | 1..1 | When the procedure was performed | |
performed[x]All Types | Content/Rules for all Types | |||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
data-absent-reason | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) | |
performedDateTime | dateTime | |||
performedPeriod | Period | |||
performedString | string | |||
performedAge | Age | |||
performedRange | Range | |||
recorder | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Who recorded the procedure |
asserter | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Person who asserts this procedure |
location | Σ | 0..1 | Reference(Location Profile) | Where the procedure happened |
reasonReference | Σ | 0..* | Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document) | The justification that the procedure was performed |
complicationDetail | 0..* | Reference(Condition Profile) | A condition that is a result of the procedure | |
usedReference | 0..* | Reference(Device Profile (Implantable) | Medication Profile | Substance) | Items used during procedure | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | |
Procedure.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/interventioncodehttps://fhir.infoway-inforoute.ca/ValueSet/interventioncode | |
Procedure.code:absentOrUnknownProcedure | required | http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ipshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | 0..* | Procedure | Procedure Profile | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
partOf | Σ | 0..* | Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile) | Part of referenced event | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
Slices for code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers. | ||||
code:absentOrUnknownProcedure | Σ | 0..1 | CodeableConcept | Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures | ||||
subject | SΣ | 1..1 | Reference(Patient Profile) | Who the procedure was performed on | ||||
encounter | Σ | 0..1 | Reference(Encounter Profile) | Encounter created as part of | ||||
performed[x] | SΣ | 1..1 | When the procedure was performed | |||||
performed[x]All Types | Content/Rules for all Types | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
data-absent-reason | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) | |||||
performedDateTime | dateTime | |||||||
performedPeriod | Period | |||||||
performedString | string | |||||||
performedAge | Age | |||||||
performedRange | Range | |||||||
recorder | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Who recorded the procedure | ||||
asserter | Σ | 0..1 | Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General)) | Person who asserts this procedure | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
actor | Σ | 1..1 | Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile | RelatedPerson | Device Profile (Implantable)) | The reference to the practitioner | ||||
onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
location | Σ | 0..1 | Reference(Location Profile) | Where the procedure happened | ||||
reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
reasonReference | Σ | 0..* | Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document) | The justification that the procedure was performed | ||||
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
complicationDetail | 0..* | Reference(Condition Profile) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
note | 0..* | Annotation | Additional information about the procedure | |||||
focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
usedReference | 0..* | Reference(Device Profile (Implantable) | Medication Profile | Substance) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard | ||||
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | preferred | https://fhir.infoway-inforoute.ca/ValueSet/interventioncodehttps://fhir.infoway-inforoute.ca/ValueSet/interventioncode | ||||
Procedure.code:absentOrUnknownProcedure | required | http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ipshttp://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips | ||||
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Procedure
Summary
Mandatory: 3 elements
Must-Support: 4 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
The Procedure.code element is used to specify a procedure that is performed.
The Procedure.code element is CodeableConcept data type meaning that more than one Coding sub-elements can be present. One of these Coding sub-elements MAY use InterventionCodeSubsetOperatingRoomProcedure value set from Canada Health Infoway.
Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").