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Patient Care Work GroupMaturity Level: 3 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Procedure resource.

Procedure
Element IdProcedure
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.

Cardinality0..*
TypeDomainResource
Procedure.identifier
Element IdProcedure.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.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Summarytrue
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.

Procedure.instantiatesCanonical
Element IdProcedure.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.

Cardinality0..*
Typecanonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)
Summarytrue
Procedure.instantiatesUri
Element IdProcedure.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.

Cardinality0..*
Typeuri
Summarytrue
Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Procedure.basedOn
Element IdProcedure.basedOn
Definition

A reference to a resource that contains details of the request for this procedure.

Cardinality0..*
TypeReference(CarePlan | ServiceRequest)
Alternate Namesfulfills
Summarytrue
Procedure.partOf
Element IdProcedure.partOf
Definition

A larger event of which this particular procedure is a component or step.

Cardinality0..*
TypeReference(Procedure | Observation | MedicationAdministration)
Alternate Namescontainer
Summarytrue
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).

Procedure.status
Element IdProcedure.status
Definition

A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Cardinality1..1
Terminology BindingEventStatus (Required)
Typecode
Is Modifiertrue (Reason: 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)
Summarytrue
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.

Procedure.statusReason
Element IdProcedure.statusReason
Definition

Captures the reason for the current state of the procedure.

Cardinality0..1
Terminology BindingProcedure Not Performed Reason (SNOMED-CT) (Example)
TypeCodeableConcept
Alternate NamesSuspended Reason; Cancelled Reason
Summarytrue
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.

Procedure.category
Element IdProcedure.category
Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Cardinality0..1
Terminology BindingProcedure Category Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Procedure.code
Element IdProcedure.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Cardinality0..1
Terminology BindingProcedure Codes (SNOMED CT) (Example)
TypeCodeableConcept
Requirements

0..1 to account for primarily narrative only resources.

Alternate Namestype
Summarytrue
Procedure.subject
Element IdProcedure.subject
Definition

The person, animal or group on which the procedure was performed.

Cardinality1..1
TypeReference(Patient | Group)
Alternate Namespatient
Summarytrue
Procedure.encounter
Element IdProcedure.encounter
Definition

The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Cardinality0..1
TypeReference(Encounter)
Summarytrue
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.

Procedure.performed[x]
Element IdProcedure.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.

Cardinality0..1
TypedateTime|Period|string|Age|Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
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.

Procedure.recorder
Element IdProcedure.recorder
Definition

Individual who recorded the record and takes responsibility for its content.

Cardinality0..1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole)
Summarytrue
Procedure.reported[x]
Element IdProcedure.reported[x]
Definition

Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the source of the report.

Cardinality0..1
Typeboolean|Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Reported data may have different rules on editing and may be visually distinguished from primary data.

Alternate Namesinformer
Summarytrue
Procedure.performer
Element IdProcedure.performer
Definition

Limited to "real" people rather than equipment.

Cardinality0..*
Summarytrue
Procedure.performer.function
Element IdProcedure.performer.function
Definition

Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Cardinality0..1
Terminology BindingProcedure Performer Role Codes (Example)
TypeCodeableConcept
Requirements

Allows disambiguation of the types of involvement of different performers.

Summarytrue
Procedure.performer.actor
Element IdProcedure.performer.actor
Definition

The practitioner who was involved in the procedure.

Cardinality1..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)
Requirements

A reference to Device supports use cases, such as pacemakers.

Summarytrue
Procedure.performer.onBehalfOf
Element IdProcedure.performer.onBehalfOf
Definition

The organization the device or practitioner was acting on behalf of.

Cardinality0..1
TypeReference(Organization)
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.

Procedure.location
Element IdProcedure.location
Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Cardinality0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Summarytrue
Procedure.reasonCode
Element IdProcedure.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.

Cardinality0..*
Terminology BindingProcedure Reason Codes (Example)
TypeCodeableConcept
Summarytrue
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.

Procedure.reasonReference
Element IdProcedure.reasonReference
Definition

The justification of why the procedure was performed.

Cardinality0..*
TypeReference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
Summarytrue
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.

Procedure.bodySite
Element IdProcedure.bodySite
Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Cardinality0..*
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summarytrue
Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Procedure.outcome
Element IdProcedure.outcome
Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Cardinality0..1
Terminology BindingProcedure Outcome Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Procedure.report
Element IdProcedure.report
Definition

This could be a histology result, pathology report, surgical report, etc.

Cardinality0..*
TypeReference(DiagnosticReport | DocumentReference | Composition)
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.

Procedure.complication
Element IdProcedure.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.

Cardinality0..*
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Procedure.complicationDetail
Element IdProcedure.complicationDetail
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Cardinality0..*
TypeReference(Condition)
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.

Procedure.followUp
Element IdProcedure.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.

Cardinality0..*
Terminology BindingProcedure Follow up Codes (SNOMED CT) (Example)
TypeCodeableConcept
Procedure.note
Element IdProcedure.note
Definition

Any other notes and comments about the procedure.

Cardinality0..*
TypeAnnotation
Procedure.focalDevice
Element IdProcedure.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.

Cardinality0..*
Procedure.focalDevice.action
Element IdProcedure.focalDevice.action
Definition

The kind of change that happened to the device during the procedure.

Cardinality0..1
Terminology BindingProcedure Device Action Codes (Preferred)
TypeCodeableConcept
Procedure.focalDevice.manipulated
Element IdProcedure.focalDevice.manipulated
Definition

The device that was manipulated (changed) during the procedure.

Cardinality1..1
TypeReference(Device)
Procedure.usedReference
Element IdProcedure.usedReference
Definition

Identifies medications, devices and any other substance used as part of the procedure.

Cardinality0..*
TypeReference(Device | Medication | Substance)
Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.

Procedure.usedCode
Element IdProcedure.usedCode
Definition

Identifies coded items that were used as part of the procedure.

Cardinality0..*
Terminology BindingFHIR Device Types (Example)
TypeCodeableConcept
Comments

For devices actually implanted or removed, use Procedure.device.