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9.3 Resource Procedure - Content

Patient Care icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Patient Compartments: Encounter, Group, Patient, Practitioner, RelatedPerson

An action that is or was performed on or for a patient, practitioner, device, organization, or location. For example, this can be a physical intervention on a patient like an operation, or less invasive like long term services, counseling, or hypnotherapy. This can be a quality or safety inspection for a location, organization, or device. This can be an accreditation procedure on a practitioner for licensing.

9.3.1 Scope and Usage

Procedure is one of the event resources in the FHIR workflow specification.

This resource is used to record the details of current and historical procedures performed on, with, or for a patient, practitioner, device, organization, or location. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise, verification of enrollment qualifications for a social program etc. Procedures may be performed by a healthcare professional, a service provider, a friend or relative or in some cases by the patient themselves.

Procedures can be performed on other non-patient subjects. For example, a procedure can represent an inspection to verify temperature or humidity for storage at a given location. Additionally, a procedure can represent the verification of the practitioner's qualifications for accreditation.

This resource provides summary information about the occurrence of the procedure and is not intended to provide real-time snapshots of a procedure as it unfolds, though for long-running procedures such as psychotherapy, it could represent summary level information about overall progress. The creation of a resource to support detailed real-time procedure information awaits the identification of a specific implementation use-case to share such information.

9.3.2 Boundaries and Relationships

The Procedure resource should not be used to capture an event if a more specific resource already exists - e.g. immunizations, drug administrations, communications, and nutrition intake. The boundary between determining whether an action is a Procedure (training or counseling) as opposed to a Communication is based on whether there's a specific intent to change the mind-set of the patient. Mere disclosure of information would be considered a Communication. A process that involves verification of the patient's comprehension or to change the patient's mental state would be a Procedure.

Note that many diagnostic processes are procedures that generate Observations and DiagnosticReports. In many cases, such an observation does not require an explicit representation of the procedure used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the Procedure resource is used to describe the activity.

Some diagnostic procedures might not have a Procedure record. The Procedure record is only necessary when there is a need to capture information about the physical intervention that was performed to capture the diagnostic information (e.g. anesthetic, incision, scope size, etc.)

A Task is a workflow step such as canceling an order, fulfilling an order, signing an order, merging a set of records, admitting a patient. Procedures are actions that are intended to result in a physical or mental change to or for the subject (e.g. surgery, physiotherapy, training, counseling). A Task resource often exists in parallel with clinical resources. For example, a Task might request fulfillment of a ServiceRequest ordering a Procedure.

9.3.3 References to this Resource

9.3.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure TU DomainResource An action that is being or was performed on an individual or entity
+ Rule: bodyStructure SHALL only be present if Procedure.bodySite is not present

Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier Σ 0..* Identifier External Identifiers for this procedure

... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | MedicationRequest) A request for this procedure

... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event

... status ?!Σ 1..1 code 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: Procedure Not Performed Reason (SNOMED-CT) (Example)
... category Σ 0..* CodeableConcept Classification of the procedure
Binding: Procedure Category Codes (SNOMED CT) (Example)

... code Σ 0..1 CodeableConcept Identification of the procedure
Binding: Procedure Codes (SNOMED CT) (Example)
... subject Σ 1..1 Reference(Patient | Group | Device | Practitioner | Organization | Location) Individual or entity the procedure was performed on
... focus ?!Σ 0..1 Reference(Patient | Group | RelatedPerson | Practitioner | Organization | CareTeam | PractitionerRole | Specimen) Who is the target of the procedure when it is not the subject of record only
... encounter Σ 0..1 Reference(Encounter) The Encounter during which this Procedure was created
... occurrence[x] Σ 0..1 When the procedure occurred or is occurring
.... occurrenceDateTime dateTime
.... occurrencePeriod Period
.... occurrenceString string
.... occurrenceAge Age
.... occurrenceRange Range
.... occurrenceTiming Timing
... recorded Σ 0..1 dateTime When the procedure was first captured in the subject's record
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... reported[x] Σ 0..1 Reported rather than primary record
.... reportedBoolean boolean
.... reportedReference Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
... performer ΣC 0..* BackboneElement Who performed the procedure and what they did
+ Rule: Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole

.... function Σ 0..1 CodeableConcept Type of performance
Binding: Participant Roles (Example)
.... actor ΣC 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | CareTeam | HealthcareService) Who performed the procedure
.... onBehalfOf C 0..1 Reference(Organization) Organization the device or practitioner was acting for
.... period 0..1 Period When the performer performed the procedure
... location Σ 0..1 Reference(Location) Where the procedure happened
... reason Σ 0..* CodeableReference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
Binding: Procedure Reason Codes (Example)

... bodySite ΣC 0..* CodeableConcept Target body sites
Binding: SNOMED CT Body Structures (Example)

... bodyStructure 0..* Reference(BodyStructure) Target body structure

... outcome Σ 0..* CodeableReference(Observation) The result of procedure
Binding: Procedure Outcome Codes (SNOMED CT) (Example)

... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure

... complication Σ 0..* CodeableReference(Condition) Complication following the procedure
Binding: Condition/Problem/Diagnosis Codes (Example)

... followUp 0..* CodeableReference(ServiceRequest | PlanDefinition) Instructions for follow up
Binding: Procedure Follow up Codes (SNOMED CT) (Example)

... note 0..* Annotation Additional information about the procedure

... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device

.... action 0..1 CodeableConcept Kind of change to device
Binding: Procedure Device Action Codes (Preferred)
.... manipulated 1..1 Reference(Device) Device that was changed
... used 0..* CodeableReference(Device | Medication | Substance | BiologicallyDerivedProduct) Items used during procedure
Binding: Device Type (Example)

... supportingInfo 0..* Reference(Any) Extra information relevant to the procedure


doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

9.3.4.1 Terminology Bindings

Path ValueSet Type Documentation
Procedure.status EventStatus Required

Codes identifying the lifecycle stage of an event.
Procedure.statusReason ProcedureNotPerformedReasonSNOMEDCT Example

Situation codes describing the reason that a procedure, which might otherwise be expected, was not performed, or a procedure that was started and was not completed. Consists of SNOMED CT codes, children of procedure contraindicated (183932001), procedure discontinued (416406003), procedure not done (416237000), procedure not indicated (428119001), procedure not offered (416064006), procedure not wanted (416432009), procedure refused (183944003), and procedure stopped (394908001) as well as 410536001 Contraindicated (qualifier value).
Procedure.category ProcedureCategoryCodesSNOMEDCT Example

Procedure Category code: A selection of relevant SNOMED CT codes.
Procedure.code ProcedureCodesSNOMEDCT Example

Procedure Code: All SNOMED CT procedure codes.
Procedure.performer.function ParticipantRoles Example

Roles of participants that may be included in a care team. Defined as: Healthcare professional (occupation) or Services (qualifier value).
Procedure.reason ProcedureReasonCodes Example

This example value set defines the set of codes that can be used to indicate a reason for a procedure.
Procedure.bodySite SNOMEDCTBodyStructures Example

This value set includes all codes from SNOMED CT icon where concept is-a 442083009 (Anatomical or acquired body site (body structure)).
Procedure.outcome ProcedureOutcomeCodesSNOMEDCT Example

Procedure Outcome code: A selection of relevant SNOMED CT codes.
Procedure.complication ConditionProblemDiagnosisCodes Example

Example value set for Condition/Problem/Diagnosis codes.
Procedure.followUp ProcedureFollowUpCodesSNOMEDCT Example

Procedure follow up codes: A selection of SNOMED CT codes relevant to procedure follow up.
Procedure.focalDevice.action ProcedureDeviceActionCodes Preferred

Example codes indicating the change that happened to the device during the procedure. Note that these are in no way complete and might not even be appropriate for some uses.
Procedure.used DeviceType Example

Codes used to identify medical devices. Includes concepts from SNOMED CT (http://www.snomed.org/) where concept is-a 49062001 (Device) and is provided as a suggestive example.

9.3.4.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img prc-1Rule Procedure.performerProcedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRoleonBehalfOf.exists() and actor.resolve().exists() implies actor.resolve().where($this is Practitioner or $this is PractitionerRole).empty()
img con-4Rule (base)bodyStructure SHALL only be present if Procedure.bodySite is not presentbodySite.exists() implies bodyStructure.empty()

9.3.4.3 Use of Procedure properties

Many of the elements of Procedure have inherent relationships and may be conveyed by the Procedure.code or in the text element of the Procedure.code property. I.e. you may be able to infer category, bodySite and even indication. Whether these other properties will be populated may vary by implementation.

Care should be taken to avoid nonsensical combinations/statements; e.g. "name=amputation, bodySite=heart".

Sometimes a complex procedure may consist of several subordinate procedures. In these cases, the list of procedures may be unwieldy for those attempting to view a procedure list. Two properties support ways of filtering and selecting procedures: the partOf property, which associates subordinate procedures to their containing procedures, and could be used to filter out those with partOf values in a higher-level list, and the category, which could be use to flag procedures that are, e.g., billable.

There are other activities that may be captured by an EHR that might not be of value to other providers (e.g. shaving, anesthesia, time admitted to recovery, etc.). The boundary between these classes may vary and is up to the judgment of the implementer. An option for capturing information of potential value that doesn't merit the name "procedure" is to use the note property.

9.3.4.4 Use of Procedure.used

For devices, these are devices that are incidental to / or used to perform the procedure - scalpels, gauze, endoscopes, etc. Devices that are the focus of the procedure should appear in Procedure.device instead.

9.3.5 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
based-on reference A request for this procedure Procedure.basedOn
(CarePlan, MedicationRequest, ServiceRequest)
category token Classification of the procedure Procedure.category
code token A code to identify a procedure Procedure.code 21 Resources
date date When the procedure occurred or is occurring Procedure.occurrence.ofType(dateTime) | Procedure.occurrence.ofType(Period) | Procedure.occurrence.ofType(Timing) 26 Resources
encounter reference The Encounter during which this Procedure was created Procedure.encounter
(Encounter)		 29 Resources
identifier token A unique identifier for a procedure Procedure.identifier 65 Resources
location reference Where the procedure happened Procedure.location
(Location)
part-of reference Part of referenced event Procedure.partOf
(Observation, Procedure, MedicationAdministration)
patient reference Search by subject - a patient Procedure.subject.where(resolve() is Patient)
(Patient)		 65 Resources
performer reference Who performed the procedure Procedure.performer.actor
(Practitioner, Organization, CareTeam, Device, Patient, HealthcareService, PractitionerRole, RelatedPerson)
reason-code token Reference to a concept (by class) Procedure.reason.concept
reason-reference reference Reference to a resource (by instance) Procedure.reason.reference
report reference Any report resulting from the procedure Procedure.report
(Composition, DiagnosticReport, DocumentReference)
status token preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Procedure.status
subject reference Search by subject Procedure.subject
(Practitioner, Group, Organization, Device, Patient, Location)