Australian Digital Health Agency FHIR Implementation Guide

This profile identifies the additional constraints, extensions, and value sets that build on and extend Procedure that are supported.

This profile is designed to set a core Procedure standard for:

• Query for procedures performed for a patient
• Record or update a procedure performed for a patient

This profile may be referred to by APIs, which will be listed here when available.

Profile specific guidance

• Procedure.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
• In an exchange with the My Health Record system Procedure.status is "completed".
• The Procedure resource can represent a reason as a code with Procedure.reasonCode, or a reference with Procedure.reasonReference to a Condition or other resource.
  • Although both are marked as must support, sending systems are not required to support both a code and a reference, but they SHALL support at least one of these elements.
  • A receiving or persisting system SHALL support both elements.
• A procedure including an implantable device should use Procedure.focalDevice with a reference to a Device resource.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from AUBaseProcedure

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A procedure in an Australian healthcare context inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
statusReason	S	0..1	CodeableConcept	Reason for current status
category	S	1..1	CodeableConcept	Classification of the procedure
code	S	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible)
subject	SC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	S	0..1	Reference(ADHA Core Encounter)	Encounter created as part of
performed[x]	S	1..1	dateTime, Period, string, Age, Range	When the procedure was performed
recorder	SC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who recorded the procedure inv-dh-pro-03: At least reference or display or a valid identifier shall be present
asserter	SC	0..1	Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)	Person who asserts this procedure
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed
​ reasonReference[x]	S	0..*	Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)	The justification that the procedure was performed
bodySite	SC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A procedure in an Australian healthcare context dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
targetBodyStructure		0..*	Reference(BodyStructure)	The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. ele-1: All FHIR elements must have a @value or children
category	SΣ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	SΣ	0..1	Reference(ADHA Core Encounter)	Encounter created as part of ele-1: All FHIR elements must have a @value or children
performed[x]	SΣ	1..1		When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	SΣC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who recorded the procedure ele-1: All FHIR elements must have a @value or children inv-dh-pro-03: At least reference or display or a valid identifier shall be present
asserter	SΣC	0..1	Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)	Person who asserts this procedure ele-1: All FHIR elements must have a @value or children
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. ele-1: All FHIR elements must have a @value or children
reasonReference	SΣ	0..*	Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)	The justification that the procedure was performed ele-1: All FHIR elements must have a @value or children
bodySite	SΣC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) ele-1: All FHIR elements must have a @value or children inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
note	S	0..*	Annotation	Additional information about the procedure ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 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	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A procedure in an Australian healthcare context inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
targetBodyStructure		0..*	Reference(BodyStructure)	The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
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(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	SΣ	1..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	Identification of the procedure Binding: Procedure (extensible)
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	SΣ	0..1	Reference(ADHA Core Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	SΣC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who recorded the procedure inv-dh-pro-03: At least reference or display or a valid identifier shall be present
asserter	SΣC	0..1	Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)	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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	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	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	SΣ	0..*	Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)	The justification that the procedure was performed
bodySite	SΣC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
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	S	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

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 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	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://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	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Differential View

This structure is derived from AUBaseProcedure

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A procedure in an Australian healthcare context inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
statusReason	S	0..1	CodeableConcept	Reason for current status
category	S	1..1	CodeableConcept	Classification of the procedure
code	S	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible)
subject	SC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	S	0..1	Reference(ADHA Core Encounter)	Encounter created as part of
performed[x]	S	1..1	dateTime, Period, string, Age, Range	When the procedure was performed
recorder	SC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who recorded the procedure inv-dh-pro-03: At least reference or display or a valid identifier shall be present
asserter	SC	0..1	Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)	Person who asserts this procedure
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed
​ reasonReference[x]	S	0..*	Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)	The justification that the procedure was performed
bodySite	SC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A procedure in an Australian healthcare context dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
targetBodyStructure		0..*	Reference(BodyStructure)	The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. ele-1: All FHIR elements must have a @value or children
category	SΣ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	SΣ	0..1	Reference(ADHA Core Encounter)	Encounter created as part of ele-1: All FHIR elements must have a @value or children
performed[x]	SΣ	1..1		When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	SΣC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who recorded the procedure ele-1: All FHIR elements must have a @value or children inv-dh-pro-03: At least reference or display or a valid identifier shall be present
asserter	SΣC	0..1	Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)	Person who asserts this procedure ele-1: All FHIR elements must have a @value or children
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. ele-1: All FHIR elements must have a @value or children
reasonReference	SΣ	0..*	Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)	The justification that the procedure was performed ele-1: All FHIR elements must have a @value or children
bodySite	SΣC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) ele-1: All FHIR elements must have a @value or children inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
note	S	0..*	Annotation	Additional information about the procedure ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 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	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A procedure in an Australian healthcare context inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
targetBodyStructure		0..*	Reference(BodyStructure)	The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
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(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	SΣ	1..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	Identification of the procedure Binding: Procedure (extensible)
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	SΣ	0..1	Reference(ADHA Core Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	SΣC	1..1	Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)	Who recorded the procedure inv-dh-pro-03: At least reference or display or a valid identifier shall be present
asserter	SΣC	0..1	Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)	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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	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	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	SΣ	0..*	Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)	The justification that the procedure was performed
bodySite	SΣC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
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	S	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

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 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	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://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	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

This structure is derived from AUBaseProcedure

Summary

Mandatory: 4 elements
Must-Support: 13 elements

Structures

This structure refers to these other structures:

• ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
• ADHA Core Encounter (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-encounter-core-1)
• ADHA Authoring PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-author-1)
• ADHA Authoring RelatedPerson (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-relatedperson-author-1)
• ADHA Core PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-core-1)
• ADHA Core RelatedPerson (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-relatedperson-core-1)
• ADHA Core Condition (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-condition-core-1)
• ADHA Core Observation (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-observation-core-1)
• ADHA Core Procedure (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-procedure-core-1)
• ADHA Core DocumentReference (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-documentreference-core-1)

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

1. SHALL support searching for all procedures for a patient using the subject:identifier search parameter:

   GET [base]/Procedure?subject:identifier={system|}[code]

   Example:

    GET [base]/Procedure?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437
   

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient (how to search by :identifier)

2. SHALL support searching using the combination subject:identifier and category search parameter:

   GET [base]/Procedure?subject:identifier={system|}[code]&category={system|}[code]

   Example:

    GET [base]/Procedure?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&category=http://snomed.info/sct|387713003
   

   Implementation Notes: Fetches a bundle of all Procedure resources with the category of "Surgical procedure" for the specified patient (how to search by :identifier)

3. SHALL support searching using the combination subject:identifier and code search parameter:

   GET [base]/Procedure?subject:identifier={system|}[code]&code={system|}[code]

   Example:

    GET [base]/Procedure?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&code=http://snomed.info/sct|34068001
   

   Implementation Notes: Fetches a bundle of all Procedure resources with the code of an 34068001 (Heart valve replacement) for the specified patient (how to search by :identifier and how to search by token)

4. SHALL support searching using the combination subject:identifier and status search parameter:

   GET [base]/Procedure?subject:identifier={system|}[code]&status={system|}[code]

   Example:

    GET [base]/Procedure?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&&status=completed
   

   Implementation Notes: Fetches a bundle of all completed Procedure resources for the specified patient.

5. SHALL support searching using the combination of the subject:identifier and date search parameters:

   GET [base]/Procedure?subject:identifier={system|}[code]&date=[date]

   Example:

    GET [base]/Procedure?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&date=ge2013-03-14
   

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient that have a date greater than or equal to 14 March 2013. (how to search by :identifier and how to search by date)