HL7.FHIR.UV.EYECARE\Opththalmic Procedure

HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1
0.1.0 - STU 1 Ballot

HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1, published by HL7 International - Patient Care WG. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/fhir-eyecare-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Opththalmic Procedure

Defining URL:

http://hl7.org/fhir/uv/eyecare/StructureDefinition/procedure-base

Version:

0.1.0

Name:

ProcedureBase

Title:

Opththalmic Procedure

Status:

Draft as of 2022-06-24 01:58:09+0000

Definition:

A profile indicating that an active ophthlmic intervention is or was performed on or for a patient. The ‘Ocular anatomical location’ profile should be used together with this profile.

Publisher:

HL7 International - Patient Care WG

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/uv/eyecare/StructureDefinition/procedure-base

Formal Views of Profile Content

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

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from Procedure

Summary

Mandatory: 1 element
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Ocular anatomical location (http://hl7.org/fhir/uv/eyecare/StructureDefinition/body-structure-eye)

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/StructureDefinition/bodySite

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
code	S	1..1	CodeableConcept	Identification of the procedure Binding: Ophthalmology Procedures Valueset (preferred)
bodySite	S	0..*	CodeableConcept	Target body sites
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
bodySite	S	0..*	Reference(BodyStructure)	Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x]	S	1..1	Reference(BodyStructure \| Ocular anatomical location)	Value of extension
Documentation for this format

Description & Constraints

Procedure

0..*

Procedure

An action that is being or was performed on a patient

id

Σ

0..1

string

Logical id of this artifact

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.

code

SΣ

1..1

CodeableConcept

Identification of the procedure
Binding: Ophthalmology Procedures Valueset (preferred)

subject

Σ

1..1

Reference(Patient | Group)

Who the procedure was performed on

encounter

Σ

0..1

Reference(Encounter)

Encounter created as part of

performed[x]

Σ

0..1

When the procedure was performed

performedDateTime

performedPeriod

performedString

performedAge

performedRange

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

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(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)

The justification that the procedure was performed

bodySite

SΣ

0..*

CodeableConcept

Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

id

0..1

string

Unique id for inter-element referencing

Slices for extension

0..*

Extension

Extension
Slice: Unordered, Open by value:url

bodySite

S

0..*

Reference(BodyStructure)

Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite

id

0..1

string

Unique id for inter-element referencing

extension

0..0

url

1..1

uri

"http://hl7.org/fhir/StructureDefinition/bodySite"

value[x]

S

1..1

Reference(BodyStructure | Ocular anatomical location)

Value of extension

coding

Σ

0..*

Coding

Code defined by a terminology system

text

Σ

0..1

string

Plain text representation of the concept

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

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
code	Σ	1..1	CodeableConcept	Identification of the procedure Binding: Ophthalmology Procedures Valueset (preferred)
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
bodySite		0..*	Reference(BodyStructure)	Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x]		1..1	Reference(BodyStructure \| Ocular anatomical location)	Value of extension
Documentation for this format

This structure is derived from Procedure

Summary

Mandatory: 1 element
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Ocular anatomical location (http://hl7.org/fhir/uv/eyecare/StructureDefinition/body-structure-eye)

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/StructureDefinition/bodySite

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
code	S	1..1	CodeableConcept	Identification of the procedure Binding: Ophthalmology Procedures Valueset (preferred)
bodySite	S	0..*	CodeableConcept	Target body sites
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
bodySite	S	0..*	Reference(BodyStructure)	Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x]	S	1..1	Reference(BodyStructure \| Ocular anatomical location)	Value of extension
Documentation for this format

Snapshot View

Description & Constraints

Procedure

0..*

Procedure

An action that is being or was performed on a patient

id

Σ

0..1

string

Logical id of this artifact

Terminology Bindings

Path	Conformance	ValueSet
Procedure.language	preferred	CommonLanguages Max Binding: AllLanguages
Procedure.status	required	EventStatus
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT)
Procedure.code	preferred	OphthalmologyProceduresValueSet
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.bodySite	example	SNOMEDCTBodyStructures
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes
Procedure.usedCode	example	FHIRDeviceTypes

Constraints

Id	Grade	Path	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	Procedure.meta	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.implicitRules	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.language	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.identifier	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.instantiatesCanonical	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.instantiatesUri	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.basedOn	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.partOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.status	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.statusReason	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.category	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.subject	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.encounter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.performed[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.recorder	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.asserter	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.performer	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.performer.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.performer.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.performer.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.performer.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.performer.function	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.performer.actor	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.performer.onBehalfOf	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.location	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.reasonCode	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.reasonReference	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.bodySite	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.bodySite.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.bodySite.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.bodySite.extension:bodySiteEye	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.bodySite.extension:bodySiteEye	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.bodySite.extension:bodySiteEye.value[x]	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.bodySite.coding	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.bodySite.text	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.outcome	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.report	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.complication	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.complicationDetail	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.followUp	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.note	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.focalDevice	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.focalDevice.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.focalDevice.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.focalDevice.modifierExtension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	Procedure.focalDevice.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	error	Procedure.focalDevice.action	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.focalDevice.manipulated	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.usedReference	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	error	Procedure.usedCode	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())