PACIO Advance Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-PMOProcedure | Version: 2.1.0 | |||
Active as of 2024-09-22 | Computable Name: ADIPMOProcedure |
This profile is used to represent both a practitioner authored portable medical order (PMO) procedure. This supports a POLST indication that there was another healthcare facilitator that was an intermediary.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
code | SΣ | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the procedure was performed on |
performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |
performedDateTime | dateTime | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status from the FHIR Standard | |
Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | (USCDI) A request for this procedure | ||||
partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
category | Σ | 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 | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the procedure was performed on | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |||||
performedDateTime | dateTime S | |||||||
performedPeriod | Period | |||||||
performedString | string | |||||||
performedAge | Age | |||||||
performedRange | Range | |||||||
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
actor | Σ | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | 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 | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
note | 0..* | Annotation | Additional information about the procedure | |||||
focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status from the FHIR Standard | ||||
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
This structure is derived from USCoreProcedureProfile
Summary
Structures
This structure refers to these other structures:
Differential View
This structure is derived from USCoreProcedureProfile
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
code | SΣ | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the procedure was performed on |
performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |
performedDateTime | dateTime | |||
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status from the FHIR Standard | |
Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
basedOn | Σ | 0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | (USCDI) A request for this procedure | ||||
partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
category | Σ | 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 | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who the procedure was performed on | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |||||
performedDateTime | dateTime S | |||||||
performedPeriod | Period | |||||||
performedString | string | |||||||
performedAge | Age | |||||||
performedRange | Range | |||||||
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
actor | Σ | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | 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 | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
note | 0..* | Annotation | Additional information about the procedure | |||||
focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status from the FHIR Standard | ||||
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | ||||
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | ||||
Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
This structure is derived from USCoreProcedureProfile
Summary
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron