QI-Core Implementation Guide
6.0.0 - STU6 United States of America flag

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 6.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

Resource Profile: QICore Procedure Not Done

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurenotdone Version: 6.0.0
Active as of 2018-08-22 Computable Name: QICoreProcedureNotDone

Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Usage

The Procedure and ProcedureNotDone profiles represent the positive and negative statements for a procedure.

The following example illustrates the use of the ProcedureNotDone profile:

define "Intermittent Pneumatic Compression Devices Not Applied":
  [ProcedureNotDone: "Application of Intermittent Pneumatic Compression Devices (IPC)"] DeviceNotApplied
    where DeviceNotApplied.statusReason in "Medical Reason" 
      or DeviceNotApplied.statusReason in "Patient Refusal"

See the patterns page for implementation and usage patterns.

Examples

Negation Example with valusetProcedure not performed due to complications; indicates that none of the procedures in the given not done value set were performed.
Negation Example with codeProcedure not performed due to complications; indicates that a specific procedure, by code, was not performed.

For a more complete discussion of representation of negation within QI-Core and quality improvement artifacts, see the Negation in QI-Core topic.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*USCoreProcedureProfileAn action that is being or was performed on a patient
pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
... recorded 1..1dateTime(QI-Core) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
... basedOn Σ0..*Reference(QICore CarePlan | QICore ServiceRequest)(QI-Core)(USCDI) A request for this procedure
... status 1..1code(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Fixed Value: not-done
... code C1..1CodeableConcept(QI-Core)(USCDI) Identification of the procedure
.... notDoneValueSet C0..1canonical(ValueSet)(QI-Core) What was not performed
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
... subject 1..1Reference(QICore Patient)(QI-Core)(USCDI) Who the procedure was performed on
... performed[x] 0..1dateTime, Period, string, Age, Range(QI-Core)(USCDI) When the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG

Constraints

IdGradePath(s)DetailsRequirements
pnd-1errorProcedureto indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
: code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*USCoreProcedureProfileAn action that is being or was performed on a patient
pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... recorded 1..1dateTime(QI-Core) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
... basedOn Σ0..*Reference(QICore CarePlan | QICore ServiceRequest)(QI-Core)(USCDI) A request for this procedure
... status ?!SΣC1..1code(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ1..1CodeableConcept(QI-Core) Reason for the current status
Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done

... code SΣC1..1CodeableConcept(QI-Core)(USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

.... notDoneValueSet C0..1canonical(ValueSet)(QI-Core) What was not performed
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who the procedure was performed on
... performed[x] SΣC0..1(QI-Core)(USCDI) When the procedure was performed
.... performedDateTimedateTime

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
: code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*USCoreProcedureProfileAn action that is being or was performed on a patient
pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... recorded 1..1dateTime(QI-Core) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(QICore CarePlan | QICore ServiceRequest)(QI-Core)(USCDI) A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣC1..1code(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ1..1CodeableConcept(QI-Core) Reason for the current status
Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done

... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code SΣC1..1CodeableConcept(QI-Core)(USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... notDoneValueSet C0..1canonical(ValueSet)(QI-Core) What was not performed
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... performed[x] SΣC0..1(QI-Core)(USCDI) When the procedure was performed
.... performedDateTimedateTime S
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
: code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()

Differential View

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*USCoreProcedureProfileAn action that is being or was performed on a patient
pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
... recorded 1..1dateTime(QI-Core) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
... basedOn Σ0..*Reference(QICore CarePlan | QICore ServiceRequest)(QI-Core)(USCDI) A request for this procedure
... status 1..1code(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Fixed Value: not-done
... code C1..1CodeableConcept(QI-Core)(USCDI) Identification of the procedure
.... notDoneValueSet C0..1canonical(ValueSet)(QI-Core) What was not performed
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
... subject 1..1Reference(QICore Patient)(QI-Core)(USCDI) Who the procedure was performed on
... performed[x] 0..1dateTime, Period, string, Age, Range(QI-Core)(USCDI) When the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG

Constraints

IdGradePath(s)DetailsRequirements
pnd-1errorProcedureto indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
: code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*USCoreProcedureProfileAn action that is being or was performed on a patient
pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... recorded 1..1dateTime(QI-Core) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
... basedOn Σ0..*Reference(QICore CarePlan | QICore ServiceRequest)(QI-Core)(USCDI) A request for this procedure
... status ?!SΣC1..1code(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ1..1CodeableConcept(QI-Core) Reason for the current status
Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done

... code SΣC1..1CodeableConcept(QI-Core)(USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

.... notDoneValueSet C0..1canonical(ValueSet)(QI-Core) What was not performed
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who the procedure was performed on
... performed[x] SΣC0..1(QI-Core)(USCDI) When the procedure was performed
.... performedDateTimedateTime

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
: code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*USCoreProcedureProfileAn action that is being or was performed on a patient
pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... recorded 1..1dateTime(QI-Core) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(QICore CarePlan | QICore ServiceRequest)(QI-Core)(USCDI) A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣC1..1code(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ1..1CodeableConcept(QI-Core) Reason for the current status
Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done

... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code SΣC1..1CodeableConcept(QI-Core)(USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... notDoneValueSet C0..1canonical(ValueSet)(QI-Core) What was not performed
URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(QICore Patient)(QI-Core)(USCDI) Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... performed[x] SΣC0..1(QI-Core)(USCDI) When the procedure was performed
.... performedDateTimedateTime S
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided
: code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()

 

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