Procedure - Epidural or Spinal Anesthesia - Birth And Fetal Death (BFDR) FHIR Implementation Guide v2.0.0

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

Resource Profile: Procedure - Epidural or Spinal Anesthesia

Official URL: http://hl7.org/fhir/us/bfdr/StructureDefinition/Procedure-epidural-or-spinal-anesthesia	Version: 2.0.0	Highlight text changes?
Standards status: Draft		Computable Name: ProcedureEpiduralOrSpinalAnesthesia
Other Identifiers: OID:2.16.840.1.113883.4.642.40.13.42.92

This Procedure profile indicates a characteristic of labor of epidural or spinal anesthesia.

IJE Mapping

Use Case	#	Description	IJE Name	Field	Type	Value Set/Comments
Natality	189	Characteristics of Labor & Delivery--Anesthesia	ESAN	-	na	See note on missing characteristics of labor and delivery data

Use Case

Description

IJE Name

Field

Type

Value Set/Comments

Natality

189

Characteristics of Labor & Delivery--Anesthesia

ESAN

See note on missing characteristics of labor and delivery data

Form Mapping

Item #	Form Field	FHIR Profile Field	Reference
45.9	Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor	-	Certificate of Live Birth
26.6	Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor	-	Facility Worksheet for the Live Birth Certificate
26.6	Characteristics of Labor and Delivery: Epidural or spinal anesthesia during labor	-	Attachment to the Facility Worksheet for the Live Birth Certificate for Multiple Births

Usages:

Refer to this Profile: Composition - Jurisdiction Live Birth Report and Composition - Provider Live Birth Report
Examples for this Profile: Procedure/procedure-epidural-or-spinal-anesthesia-jada-ann-quinn

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

Key Elements Table
Differential Table
Snapshot Table
Statistics/References
All

Name	Flags	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient Constraints: us-core-7
Procedure.implicitRules	This element is a modifier element. This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Procedure.modifierExtension	This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Procedure.status	This element is a modifier element. This element must be supported. This element is included in summaries. C	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required)
Procedure.category	This element is included in summaries.	1..1	CodeableConcept	Characteristics of labor and 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: `{ "coding" : [ { "system" : "http://loinc.org", "code" : "73813-8" } ] }`
Procedure.code	This element must be supported. This element is included in summaries.	1..1	CodeableConcept	Epidural anesthesia (procedure) Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: `{ "coding" : [ { "system" : "http://snomed.info/sct", "code" : "18946005" } ] }`
Procedure.subject	This element must be supported. This element is included in summaries.	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
Procedure.performed[x]	This element must be supported. This element is included in summaries. C	0..1		When the procedure was performed
Procedure.performed[x].performedDateTime			dateTime This target must be supported.
Procedure.performed[x].performedPeriod			Period
Procedure.performed[x].performedString			string
Procedure.performed[x].performedAge			Age
Procedure.performed[x].performedRange			Range
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Procedure.status	Base	required	EventStatus	📦4.0.1	FHIR Std.
Procedure.category	Base	example	Procedure Category Codes (SNOMED CT)	📦4.0.1	FHIR Std.
Procedure.code	Base	extensible	US Core Procedure Codes	📦5.0.1	US Core v5.0

Constraints

Grade

Path(s)

Description

Expression

This structure is derived from USCoreProcedureProfile

Name	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
Procedure	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient
Procedure.category	1..1	CodeableConcept	Characteristics of labor and delivery [US Standard Certificate of Live Birth] Required Pattern: `{ "coding" : [ { "system" : "http://loinc.org", "code" : "73813-8" } ] }`
Procedure.code	1..1	CodeableConcept	Epidural anesthesia (procedure) Required Pattern: `{ "coding" : [ { "system" : "http://snomed.info/sct", "code" : "18946005" } ] }`
Procedure.subject	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
Documentation for this format

Description & Constraints Filter:

Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
Constraints: us-core-7

Procedure.id This element is included in summaries. 0..1 id Logical id of this artifact

Procedure.meta This element is included in summaries. 0..1 Meta Metadata about the resource

Procedure.implicitRules This element is a modifier element. This element is included in summaries. 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

Procedure.text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements

Procedure.contained 0..* Resource Contained, inline Resources

Procedure.extension 0..* Extension Additional content defined by implementations

Procedure.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored

Procedure.identifier This element is included in summaries. 0..* Identifier External Identifiers for this procedure

Procedure.instantiatesCanonical This element is included in summaries. 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition

Procedure.instantiatesUri This element is included in summaries. 0..* uri Instantiates external protocol or definition

Procedure.basedOn This element is included in summaries. 0..* Reference(CarePlan | ServiceRequest) A request for this procedure

Procedure.partOf This element is included in summaries. 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event

Procedure.statusReason This element is included in summaries. 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

category

1..1

CodeableConcept

Characteristics of labor and 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:

{
  "coding" : [
    {
      "system" : "http://loinc.org",
      "code" : "73813-8"
    }
  ]
}

code

1..1

CodeableConcept

Epidural anesthesia (procedure)
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
Required Pattern:

{
  "coding" : [
    {
      "system" : "http://snomed.info/sct",
      "code" : "18946005"
    }
  ]
}

Procedure.subject This element must be supported. This element is included in summaries. 1..1 Reference(Patient - Mother Vital Records) Who the procedure was performed on

Procedure.encounter This element is included in summaries. 0..1 Reference(Encounter) Encounter created as part of

Procedure.performed[x] This element must be supported. This element is included in summaries. C 0..1 When the procedure was performed

Procedure.performed[x].performedDateTime dateTime This target must be supported.

Procedure.performed[x].performedPeriod Period

Procedure.performed[x].performedString string

Procedure.performed[x].performedAge Age

Procedure.performed[x].performedRange Range

Procedure.recorder This element is included in summaries. 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure

Procedure.asserter This element is included in summaries. 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure

Procedure.performer This element is included in summaries. 0..* BackboneElement The people who performed the procedure

Procedure.performer.id 0..1 string Unique id for inter-element referencing

Procedure.performer.extension 0..* Extension Additional content defined by implementations

Procedure.performer.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized

Procedure.performer.function This element is included in summaries. 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

Procedure.performer.onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for

Procedure.location This element is included in summaries. 0..1 Reference(Location) Where the procedure happened

Procedure.reasonCode This element is included in summaries. 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.

Procedure.reasonReference This element is included in summaries. 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed

Procedure.bodySite This element is included in summaries. 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

Procedure.outcome This element is included in summaries. 0..1 CodeableConcept The result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

Procedure.report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure

Procedure.complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.

Procedure.complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure

Procedure.followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.

Procedure.note 0..* Annotation Additional information about the procedure

Procedure.focalDevice 0..* BackboneElement Manipulated, implanted, or removed device

Procedure.focalDevice.id 0..1 string Unique id for inter-element referencing

Procedure.focalDevice.extension 0..* Extension Additional content defined by implementations

Procedure.focalDevice.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized

Procedure.focalDevice.action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

Procedure.focalDevice.manipulated 1..1 Reference(Device) Device that was changed

Procedure.usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure

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	Status	Usage	ValueSet	Version	Source
Procedure.language	Base	preferred	Common Languages	📦4.0.1	FHIR Std.
Procedure.status	Base	required	EventStatus	📦4.0.1	FHIR Std.
Procedure.statusReason	Base	example	Procedure Not Performed Reason (SNOMED-CT)	📦4.0.1	FHIR Std.
Procedure.category	Base	example	Procedure Category Codes (SNOMED CT)	📦4.0.1	FHIR Std.
Procedure.code	Base	extensible	US Core Procedure Codes	📦5.0.1	US Core v5.0
Procedure.performer.function	Base	example	Procedure Performer Role Codes	📦4.0.1	FHIR Std.
Procedure.reasonCode	Base	example	Procedure Reason Codes	📦4.0.1	FHIR Std.
Procedure.bodySite	Base	example	SNOMED CT Body Structures	📦4.0.1	FHIR Std.
Procedure.outcome	Base	example	Procedure Outcome Codes (SNOMED CT)	📦4.0.1	FHIR Std.
Procedure.complication	Base	example	Condition/Problem/Diagnosis Codes	📦4.0.1	FHIR Std.
Procedure.followUp	Base	example	Procedure Follow up Codes (SNOMED CT)	📦4.0.1	FHIR Std.
Procedure.focalDevice.action	Base	preferred	Procedure Device Action Codes	📦4.0.1	FHIR Std.
Procedure.usedCode	Base	example	FHIR Device Types	📦4.0.1	FHIR Std.

Constraints

Grade

Path(s)

Description

Expression

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)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient Constraints: us-core-7
Procedure.implicitRules	This element is a modifier element. This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Procedure.modifierExtension	This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Procedure.status	This element is a modifier element. This element must be supported. This element is included in summaries. C	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required)
Procedure.category	This element is included in summaries.	1..1	CodeableConcept	Characteristics of labor and 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: `{ "coding" : [ { "system" : "http://loinc.org", "code" : "73813-8" } ] }`
Procedure.code	This element must be supported. This element is included in summaries.	1..1	CodeableConcept	Epidural anesthesia (procedure) Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: `{ "coding" : [ { "system" : "http://snomed.info/sct", "code" : "18946005" } ] }`
Procedure.subject	This element must be supported. This element is included in summaries.	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
Procedure.performed[x]	This element must be supported. This element is included in summaries. C	0..1		When the procedure was performed
Procedure.performed[x].performedDateTime			dateTime This target must be supported.
Procedure.performed[x].performedPeriod			Period
Procedure.performed[x].performedString			string
Procedure.performed[x].performedAge			Age
Procedure.performed[x].performedRange			Range
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Procedure.status	Base	required	EventStatus	📦4.0.1	FHIR Std.
Procedure.category	Base	example	Procedure Category Codes (SNOMED CT)	📦4.0.1	FHIR Std.
Procedure.code	Base	extensible	US Core Procedure Codes	📦5.0.1	US Core v5.0

Constraints

Grade

Path(s)

Description

Expression

Differential View

This structure is derived from USCoreProcedureProfile

Name	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
Procedure	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient
Procedure.category	1..1	CodeableConcept	Characteristics of labor and delivery [US Standard Certificate of Live Birth] Required Pattern: `{ "coding" : [ { "system" : "http://loinc.org", "code" : "73813-8" } ] }`
Procedure.code	1..1	CodeableConcept	Epidural anesthesia (procedure) Required Pattern: `{ "coding" : [ { "system" : "http://snomed.info/sct", "code" : "18946005" } ] }`
Procedure.subject	1..1	Reference(Patient - Mother Vital Records)	Who the procedure was performed on
Documentation for this format

Snapshot ViewView