Birth And Fetal Death (BFDR) FHIR Implementation Guide, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-bfdr/ and changes regularly. See the Directory of published versions

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Resource Profile: Procedure - Final Route and Method of Delivery

This profile represents the final route and method of delivery.

Usage:

• Refer to this Resource Profile: Composition - Jurisdiction Fetal Death Report, Composition - Jurisdiction Live Birth Report, Composition - Provider Fetal Death Report and Composition - Provider Live Birth Report
• Examples for this Resource Profile: Procedure/procedure-final-route-method-delivery-babyg-quinn and Procedure/procedure-final-route-method-delivery-not-named

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure			USCoreProcedureProfile
category		1..1	CodeableConcept	Final route and method of delivery [US Standard Certificate of Live Birth] Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73762-7
code		1..1	CodeableConcept	The value set contains the list of the possible routes by which the infant or fetus may be delivered. Binding: Delivery Routes (required): Delivery Routes (NCHS)
subject		1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
reasonReference		0..*	Reference(Observation - Labor Trial Attempted)	If cesarean, was a trial of labor attempted?
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	required	DeliveryRoutesVS http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes from this IG

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
category	Σ	1..1	CodeableConcept	Final route and method of delivery [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73762-7
code	SΣ	1..1	CodeableConcept	The value set contains the list of the possible routes by which the infant or fetus may be delivered. Binding: Delivery Routes (required): Delivery Routes (NCHS)
subject	SΣ	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime
reasonReference	Σ	0..*	Reference(Observation - Labor Trial Attempted)	If cesarean, was a trial of labor attempted?
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.category	example	Pattern: LOINC Code 73762-7 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	required	DeliveryRoutesVS http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes from this IG

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
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. Additional Bindings Purpose AllLanguages Max Binding
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 | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
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	1..1	CodeableConcept	Final route and method of delivery [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73762-7
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	The value set contains the list of the possible routes by which the infant or fetus may be delivered. Binding: Delivery Routes (required): Delivery Routes (NCHS)
subject	SΣ	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	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 | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	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(Observation - Labor Trial Attempted)	If cesarean, was a trial of labor attempted?
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)	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 | Medication | 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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status 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	Pattern: LOINC Code 73762-7 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	required	DeliveryRoutesVS http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	example	SNOMEDCTBodyStructures http://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/DiagnosisCodes http://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	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

This structure is derived from USCoreProcedureProfile

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

• Patient - Mother Vital Records (http://hl7.org/fhir/us/vr-common-library/StructureDefinition/Patient-mother-vr)
• Observation - Labor Trial Attempted (http://hl7.org/fhir/us/bfdr/StructureDefinition/Observation-labor-trial-attempted)

Differential View

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure			USCoreProcedureProfile
category		1..1	CodeableConcept	Final route and method of delivery [US Standard Certificate of Live Birth] Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73762-7
code		1..1	CodeableConcept	The value set contains the list of the possible routes by which the infant or fetus may be delivered. Binding: Delivery Routes (required): Delivery Routes (NCHS)
subject		1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
reasonReference		0..*	Reference(Observation - Labor Trial Attempted)	If cesarean, was a trial of labor attempted?
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	required	DeliveryRoutesVS http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
category	Σ	1..1	CodeableConcept	Final route and method of delivery [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73762-7
code	SΣ	1..1	CodeableConcept	The value set contains the list of the possible routes by which the infant or fetus may be delivered. Binding: Delivery Routes (required): Delivery Routes (NCHS)
subject	SΣ	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime
reasonReference	Σ	0..*	Reference(Observation - Labor Trial Attempted)	If cesarean, was a trial of labor attempted?
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.category	example	Pattern: LOINC Code 73762-7 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	required	DeliveryRoutesVS http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
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. Additional Bindings Purpose AllLanguages Max Binding
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 | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
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	1..1	CodeableConcept	Final route and method of delivery [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 73762-7
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	The value set contains the list of the possible routes by which the infant or fetus may be delivered. Binding: Delivery Routes (required): Delivery Routes (NCHS)
subject	SΣ	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	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 | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	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(Observation - Labor Trial Attempted)	If cesarean, was a trial of labor attempted?
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)	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 | Medication | 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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status 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	Pattern: LOINC Code 73762-7 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	required	DeliveryRoutesVS http://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-delivery-routes from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	example	SNOMEDCTBodyStructures http://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/DiagnosisCodes http://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	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

This structure is derived from USCoreProcedureProfile

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

• Patient - Mother Vital Records (http://hl7.org/fhir/us/vr-common-library/StructureDefinition/Patient-mother-vr)
• Observation - Labor Trial Attempted (http://hl7.org/fhir/us/bfdr/StructureDefinition/Observation-labor-trial-attempted)

Other representations of profile: CSV, Excel, Schematron