International Patient Summary Implementation Guide, published by HL7 International / Patient Care. 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-ips/ and changes regularly. See the Directory of published versions
Page standards status: Trial-use | Maturity Level: 2 |
Definitions for the Procedure-uv-ips resource profile.
Guidance on how to interpret the contents of this table can be found here
0. Procedure | |
2. Procedure.code | |
Definition | Identification of the procedure or recording of "absence of relevant procedures" or of "procedures unknown". |
Control | 1..? |
Binding | The codes SHOULD be taken from Procedures - IPS (preferred to http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips )SNOMED CT procedure code set or a code for absent/unknown procedure |
Type | CodeableConcept(Codeable Concept (IPS)) |
Must Support | true |
4. Procedure.subject | |
Definition | The person on which the procedure was performed. |
Type | Reference(Patient (IPS)) |
Must Support | true |
6. Procedure.subject.reference | |
Control | 1..? |
Must Support | true |
8. Procedure.performed[x] | |
Control | 1..? |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Must Support | true |
10. Procedure.performed[x].extension:data-absent-reason | |
Slice Name | data-absent-reason |
Definition | Provides a reason why the performed is missing. |
Short | performed[x] absence reason |
Control | 0..1 |
Type | Extension(Data Absent Reason) (Extension Type: code) |
Must Support | true |
12. Procedure.asserter | |
Must Support | false |
14. Procedure.performer | |
Must Support | false |
16. Procedure.performer.actor | |
Type | Reference(Patient (IPS), RelatedPerson, Device - performer, observer, Practitioner (IPS), PractitionerRole (IPS), Organization (IPS)) |
Must Support | false |
18. Procedure.performer.onBehalfOf | |
Type | Reference(Organization (IPS)) |
Must Support | false |
20. Procedure.bodySite | |
Binding | For example codes, see SNOMEDCTBodyStructures (example to http://hl7.org/fhir/ValueSet/body-site ) |
Type | CodeableConcept(Codeable Concept (IPS)) |
Guidance on how to interpret the contents of this table can be found here
0. Procedure | |
Definition | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. |
Short | An action that is being or was performed on a patient |
Control | 0..* |
Is Modifier | false |
Summary | false |
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
2. Procedure.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Short | A set of rules under which this content was created |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
4. Procedure.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
6. Procedure.status | |
Definition | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. |
Short | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
Comments | The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
Control | 1..1 |
Binding | The codes SHALL be taken from EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )A code specifying the state of the procedure. |
Type | code |
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
8. Procedure.code | |
Definition | Identification of the procedure or recording of "absence of relevant procedures" or of "procedures unknown". The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). |
Short | Concept - reference to a terminology or just textIdentification of the procedure |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
Control | 10..1 This element is affected by the following invariants: ele-1 |
Binding | The codes SHOULD be taken from For example codes, see Procedures - IPShttp://hl7.org/fhir/ValueSet/procedure-code (preferred to http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips )SNOMED CT procedure code set or a code for absent/unknown procedure A code to identify a specific procedure . |
Type | CodeableConcept(Codeable Concept (IPS)) |
Is Modifier | false |
Must Support | true |
Requirements | 0..1 to account for primarily narrative only resources. |
Alternate Names | type |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
10. Procedure.subject | |
Definition | The person on which the procedure was performed. The person, animal or group on which the procedure was performed. |
Short | Who the procedure was performed on |
Control | 1..1 |
Type | Reference(Patient (IPS), Patient, Group) |
Is Modifier | false |
Must Support | true |
Summary | true |
Alternate Names | patient |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
12. Procedure.subject.reference | |
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. |
Short | Literal reference, Relative, internal or absolute URL |
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. |
Control | 10..1 This element is affected by the following invariants: ref-1 |
Type | string |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
14. Procedure.performed[x] | |
Definition | Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. |
Short | When the procedure was performed |
Comments | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. |
Control | 10..1 |
Type | Choice of: dateTime, Period, string, Age, Range |
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] |
Is Modifier | false |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
16. Procedure.performed[x].extension:data-absent-reason | |
Slice Name | data-absent-reason |
Definition | Provides a reason why the performed is missing. |
Short | performed[x] absence reason |
Control | 0..1 |
Type | Extension(Data Absent Reason) (Extension Type: code) |
Is Modifier | false |
Must Support | true |
Summary | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
18. Procedure.asserter | |
Definition | Individual who is making the procedure statement. |
Short | Person who asserts this procedure |
Control | 0..1 |
Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole) |
Is Modifier | false |
Must Support | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
20. Procedure.performer | |
Definition | Limited to "real" people rather than equipment. |
Short | The people who performed the procedure |
Control | 0..* |
Type | BackboneElement |
Is Modifier | false |
Must Support | false |
Summary | true |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
22. Procedure.performer.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Short | Extensions that cannot be ignored even if unrecognized |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Control | 0..* |
Type | Extension |
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
Summary | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content, modifiers |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists()) |
24. Procedure.performer.actor | |
Definition | The practitioner who was involved in the procedure. |
Short | The reference to the practitioner |
Control | 1..1 |
Type | Reference(Patient (IPS), RelatedPerson, Device - performer, observer, Practitioner (IPS), PractitionerRole (IPS), Organization (IPS), Practitioner, PractitionerRole, Organization, Patient, Device) |
Is Modifier | false |
Must Support | false |
Summary | true |
Requirements | A reference to Device supports use cases, such as pacemakers. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
26. Procedure.performer.onBehalfOf | |
Definition | The organization the device or practitioner was acting on behalf of. |
Short | Organization the device or practitioner was acting for |
Control | 0..1 |
Type | Reference(Organization (IPS), Organization) |
Is Modifier | false |
Must Support | false |
Summary | false |
Requirements | Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
28. Procedure.bodySite | |
Definition | A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. |
Short | Concept - reference to a terminology or just textTarget body sites |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure. |
Control | 0..* This element is affected by the following invariants: ele-1 |
Binding | For example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site (example to http://hl7.org/fhir/ValueSet/body-site ) |
Type | CodeableConcept(Codeable Concept (IPS)) |
Is Modifier | false |
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here
0. Procedure | |||||
Definition | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. | ||||
Short | An action that is being or was performed on a patient | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. Procedure.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. Procedure.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about the resource | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. Procedure.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
8. Procedure.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
10. Procedure.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. Procedure.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
14. Procedure.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
16. Procedure.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
18. Procedure.identifier | |||||
Definition | Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. | ||||
Short | External Identifiers for this procedure | ||||
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
20. Procedure.instantiatesCanonical | |||||
Definition | The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. | ||||
Short | Instantiates FHIR protocol or definition | ||||
Control | 0..* | ||||
Type | canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. Procedure.instantiatesUri | |||||
Definition | The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. | ||||
Short | Instantiates external protocol or definition | ||||
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. | ||||
Control | 0..* | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. Procedure.basedOn | |||||
Definition | A reference to a resource that contains details of the request for this procedure. | ||||
Short | A request for this procedure | ||||
Control | 0..* | ||||
Type | Reference(CarePlan, ServiceRequest) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | fulfills | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. Procedure.partOf | |||||
Definition | A larger event of which this particular procedure is a component or step. | ||||
Short | Part of referenced event | ||||
Comments | The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). | ||||
Control | 0..* | ||||
Type | Reference(Procedure, Observation, MedicationAdministration) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | container | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. Procedure.status | |||||
Definition | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. | ||||
Short | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | ||||
Comments | The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from EventStatus (required to http://hl7.org/fhir/ValueSet/event-status|4.0.1 )A code specifying the state of the procedure. | ||||
Type | code | ||||
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
30. Procedure.statusReason | |||||
Definition | Captures the reason for the current state of the procedure. | ||||
Short | Reason for current status | ||||
Comments | This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedureNotPerformedReason(SNOMED-CT) (example to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason )A code that identifies the reason a procedure was not performed. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Alternate Names | Suspended Reason, Cancelled Reason | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
32. Procedure.category | |||||
Definition | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). | ||||
Short | Classification of the procedure | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedureCategoryCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-category )A code that classifies a procedure for searching, sorting and display purposes. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
34. Procedure.code | |||||
Definition | Identification of the procedure or recording of "absence of relevant procedures" or of "procedures unknown". | ||||
Short | Concept - reference to a terminology or just text | ||||
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Binding | The codes SHOULD be taken from Procedures - IPS (preferred to http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips )SNOMED CT procedure code set or a code for absent/unknown procedure | ||||
Type | CodeableConcept(Codeable Concept (IPS)) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Requirements | 0..1 to account for primarily narrative only resources. | ||||
Alternate Names | type | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
36. Procedure.subject | |||||
Definition | The person on which the procedure was performed. | ||||
Short | Who the procedure was performed on | ||||
Control | 1..1 | ||||
Type | Reference(Patient (IPS)) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | patient | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
38. Procedure.subject.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
40. Procedure.subject.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Procedure.subject.extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
42. Procedure.subject.reference | |||||
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. | ||||
Short | Literal reference, Relative, internal or absolute URL | ||||
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. | ||||
Control | 1..1 This element is affected by the following invariants: ref-1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. Procedure.subject.type | |||||
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). | ||||
Short | Type the reference refers to (e.g. "Patient") | ||||
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. | ||||
Control | 0..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to http://hl7.org/fhir/ValueSet/resource-types )Aa resource (or, for logical models, the URI of the logical model). | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
46. Procedure.subject.identifier | |||||
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. | ||||
Short | Logical reference, when literal reference is not known | ||||
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
48. Procedure.subject.display | |||||
Definition | Plain text narrative that identifies the resource in addition to the resource reference. | ||||
Short | Text alternative for the resource | ||||
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
50. Procedure.encounter | |||||
Definition | The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. | ||||
Short | Encounter created as part of | ||||
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. | ||||
Control | 0..1 | ||||
Type | Reference(Encounter) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
52. Procedure.performed[x] | |||||
Definition | Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. | ||||
Short | When the procedure was performed | ||||
Comments | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. | ||||
Control | 1..1 | ||||
Type | Choice of: dateTime, Period, string, Age, Range | ||||
[x] Note | SeeChoice of Data Typesfor further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
54. Procedure.performed[x].id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
56. Procedure.performed[x].extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on Procedure.performed[x].extension . The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
58. Procedure.performed[x].extension:data-absent-reason | |||||
Slice Name | data-absent-reason | ||||
Definition | Provides a reason why the performed is missing. | ||||
Short | performed[x] absence reason | ||||
Control | 0..1 | ||||
Type | Extension(Data Absent Reason) (Extension Type: code) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
60. Procedure.recorder | |||||
Definition | Individual who recorded the record and takes responsibility for its content. | ||||
Short | Who recorded the procedure | ||||
Control | 0..1 | ||||
Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. Procedure.asserter | |||||
Definition | Individual who is making the procedure statement. | ||||
Short | Person who asserts this procedure | ||||
Control | 0..1 | ||||
Type | Reference(Patient, RelatedPerson, Practitioner, PractitionerRole) | ||||
Is Modifier | false | ||||
Must Support | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
64. Procedure.performer | |||||
Definition | Limited to "real" people rather than equipment. | ||||
Short | The people who performed the procedure | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. Procedure.performer.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
68. Procedure.performer.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
70. Procedure.performer.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
72. Procedure.performer.function | |||||
Definition | Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. | ||||
Short | Type of performance | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedurePerformerRoleCodes (example to http://hl7.org/fhir/ValueSet/performer-role )A code that identifies the role of a performer of the procedure. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Allows disambiguation of the types of involvement of different performers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. Procedure.performer.actor | |||||
Definition | The practitioner who was involved in the procedure. | ||||
Short | The reference to the practitioner | ||||
Control | 1..1 | ||||
Type | Reference(Patient (IPS), RelatedPerson, Device - performer, observer, Practitioner (IPS), PractitionerRole (IPS), Organization (IPS)) | ||||
Is Modifier | false | ||||
Must Support | false | ||||
Summary | true | ||||
Requirements | A reference to Device supports use cases, such as pacemakers. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. Procedure.performer.onBehalfOf | |||||
Definition | The organization the device or practitioner was acting on behalf of. | ||||
Short | Organization the device or practitioner was acting for | ||||
Control | 0..1 | ||||
Type | Reference(Organization (IPS)) | ||||
Is Modifier | false | ||||
Must Support | false | ||||
Summary | false | ||||
Requirements | Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. Procedure.location | |||||
Definition | The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. | ||||
Short | Where the procedure happened | ||||
Control | 0..1 | ||||
Type | Reference(Location) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Ties a procedure to where the records are likely kept. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. Procedure.reasonCode | |||||
Definition | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. | ||||
Short | Coded reason procedure performed | ||||
Comments | Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. | ||||
Control | 0..* | ||||
Binding | For example codes, see ProcedureReasonCodes (example to http://hl7.org/fhir/ValueSet/procedure-reason )A code that identifies the reason a procedure is required. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. Procedure.reasonReference | |||||
Definition | The justification of why the procedure was performed. | ||||
Short | The justification that the procedure was performed | ||||
Comments | It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. | ||||
Control | 0..* | ||||
Type | Reference(Condition, Observation, Procedure, DiagnosticReport, DocumentReference) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
84. Procedure.bodySite | |||||
Definition | A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text. | ||||
Short | Concept - reference to a terminology or just text | ||||
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. | ||||
Control | 0..* This element is affected by the following invariants: ele-1 | ||||
Binding | For example codes, see SNOMEDCTBodyStructures (example to http://hl7.org/fhir/ValueSet/body-site ) | ||||
Type | CodeableConcept(Codeable Concept (IPS)) | ||||
Is Modifier | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
86. Procedure.outcome | |||||
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed? | ||||
Short | The result of procedure | ||||
Comments | If outcome contains narrative text only, it can be captured using the CodeableConcept.text. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedureOutcomeCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-outcome )An outcome of a procedure - whether it was resolved or otherwise. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
88. Procedure.report | |||||
Definition | This could be a histology result, pathology report, surgical report, etc. | ||||
Short | Any report resulting from the procedure | ||||
Comments | There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports. | ||||
Control | 0..* | ||||
Type | Reference(DiagnosticReport, DocumentReference, Composition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. Procedure.complication | |||||
Definition | Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. | ||||
Short | Complication following the procedure | ||||
Comments | If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. | ||||
Control | 0..* | ||||
Binding | For example codes, see Condition/Problem/DiagnosisCodes (example to http://hl7.org/fhir/ValueSet/condition-code )Codes describing complications that resulted from a procedure. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. Procedure.complicationDetail | |||||
Definition | Any complications that occurred during the procedure, or in the immediate post-performance period. | ||||
Short | A condition that is a result of the procedure | ||||
Control | 0..* | ||||
Type | Reference(Condition) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
94. Procedure.followUp | |||||
Definition | If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. | ||||
Short | Instructions for follow up | ||||
Control | 0..* | ||||
Binding | For example codes, see ProcedureFollowUpCodes(SNOMEDCT) (example to http://hl7.org/fhir/ValueSet/procedure-followup )Specific follow up required for a procedure e.g. removal of sutures. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
96. Procedure.note | |||||
Definition | Any other notes and comments about the procedure. | ||||
Short | Additional information about the procedure | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
98. Procedure.focalDevice | |||||
Definition | A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. | ||||
Short | Manipulated, implanted, or removed device | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
100. Procedure.focalDevice.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
102. Procedure.focalDevice.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
104. Procedure.focalDevice.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
106. Procedure.focalDevice.action | |||||
Definition | The kind of change that happened to the device during the procedure. | ||||
Short | Kind of change to device | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodes (preferred to http://hl7.org/fhir/ValueSet/device-action )A kind of change that happened to the device during the procedure. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
108. Procedure.focalDevice.manipulated | |||||
Definition | The device that was manipulated (changed) during the procedure. | ||||
Short | Device that was changed | ||||
Control | 1..1 | ||||
Type | Reference(Device) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
110. Procedure.usedReference | |||||
Definition | Identifies medications, devices and any other substance used as part of the procedure. | ||||
Short | Items used during procedure | ||||
Comments | For devices actually implanted or removed, use Procedure.device. | ||||
Control | 0..* | ||||
Type | Reference(Device, Medication, Substance) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | Used for tracking contamination, etc. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
112. Procedure.usedCode | |||||
Definition | Identifies coded items that were used as part of the procedure. | ||||
Short | Coded items used during the procedure | ||||
Comments | For devices actually implanted or removed, use Procedure.device. | ||||
Control | 0..* | ||||
Binding | For example codes, see FHIRDeviceTypes (example to http://hl7.org/fhir/ValueSet/device-kind )Codes describing items used during a procedure. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |