Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft
Australian Digital Health Agency FHIR Implementation Guide, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.2.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/ci-fhir-r4/ and changes regularly. See the Directory of published versions
Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-procedure-core-1 | Version: 1.0.0 | |||
Active as of 2024-09-12 | Computable Name: ADHAProcedureCore | |||
Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/. |
The purpose of this profile is to provide a core representation of a procedure for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.
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:
This profile may be referred to by APIs, which will be listed here when available.
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.Procedure.status
is "completed".Procedure.reasonCode
, or a reference with Procedure.reasonReference
to a Condition or other resource.
Procedure.focalDevice
with a reference to a Device resource.Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
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 |
Path | Conformance | ValueSet | URI |
Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | |
Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
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 |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
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 | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
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 |
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 |
note | S | 0..* | Annotation | Additional information about the procedure |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://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 | |
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | |
Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
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.
| |||||
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 |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|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 | ||||
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
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:
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 |
Path | Conformance | ValueSet | URI |
Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | |
Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
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 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 |
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 | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
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 |
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 |
note | S | 0..* | Annotation | Additional information about the procedure |
Documentation for this format |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://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 | |
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | |
Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
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.
| |||||
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 |
Path | Conformance | ValueSet | URI | |||
Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|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 | ||||
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | ||||
Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | ||||
Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | ||||
Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | ||||
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | ||||
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | ||||
Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard |
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:
Other representations of profile: CSV, Excel, Schematron
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.
Name | Type | Conformance | Description | Path |
---|---|---|---|---|
category | token | SHALL | Classification of the procedure | Procedure.category |
subject:identifier | token | SHALL | Search by subject | Procedure.subject.identifier |
code | token | SHALL | A code to identify a procedure | Procedure.code |
date | token | SHALL | When the procedure was performed | Procedure.performed |
status | token | SHALL | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | Procedure.status |
The following search parameters and search parameter combinations SHALL be supported:
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)
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)
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)
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.
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)