US Quality Core Implementation Guide
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US Quality Core Implementation Guide, published by ASTP. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/FHIR/us-quality-core/ and changes regularly. See the Directory of published versions

Resource Profile: US Quality Core Procedure

Official URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-procedure Version: 0.1.0
Active as of 2026-03-31 Computable Name: USQualityCoreProcedure

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

Usage

To create an expression specifically requesting information that a procedure intentionally did not occur for a medical, patient or system reason, use the profile USQualityCore-Procedurenotdone.

The following example illustrates the use of the Procedure profile:

define "Application of Intermittent Pneumatic Compression Devices":
  ["Procedure": "Application of Intermittent Pneumatic Compression Devices (IPC)"] DeviceApplied
    where DeviceApplied.status = 'completed'

See the patterns page for implementation and usage patterns.

Examples

Appendectomy Example

USCDI+ Quality Elements:

  • extension:recorded: (USCDI+ Quality) When the procedure was first captured in the subject's record
  • partOf: (USCDI+ Quality) Part of referenced event
  • status: (USCDI+ Quality) (USCDI) preparation \| in-progress \| ​on-hold​ \| stopped​ \| completed \| entered-in-error​ \| unknown​
  • statusReason: (USCDI+ Quality) Reason for current status
  • code: (USCDI+ Quality) (USCDI) Identification of the procedure
  • performed[x]: (USCDI+ Quality) (USCDI) When the procedure was performed
  • reasonCode: (USCDI+ Quality) Coded reason procedure performed
  • reasonReference: (USCDI+ Quality) The justification that the procedure was performed

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
Constraints: us-core-7
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:recorded 0..1 dateTime (USCDI+ Quality) When the procedure was first captured in the subject's record
URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-recorded
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) (USCDI+ Quality) Part of referenced event
... status ?!SΣC 1..1 code (USCDI+ Quality) (USCDI) preparation | in-progress | ​on-hold​ | stopped​ | completed | entered-in-error​ | unknown​
Binding: Non-Negative Event Status (required)
... statusReason Σ 0..1 CodeableConcept (USCDI+ Quality) Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category Σ 0..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 (USCDI+ Quality) (USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) Who the procedure was performed on
... performed[x] SΣC 0..1 (USCDI+ Quality) (USCDI) When the procedure was performed
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... reasonCode Σ 0..* CodeableConcept (USCDI+ Quality) Coded reason procedure performed
Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(US Quality Core Condition Encounter Diagnosis | US Quality Core Condition Problems Health Concerns | US Quality Core DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (USCDI+ Quality) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required Non-Negative Event Status 📦0.1.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦6.1.0 US Core v6.1
Procedure.reasonCode Base preferred Procedure Reason Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Procedure If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Procedure 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Procedure If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Procedure If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Procedure A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-7 error Procedure Performed SHALL be present if the status is 'completed' or 'in-progress' (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* USCoreProcedureProfile An action that is being or was performed on a patient
... implicitRules 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:recorded 0..1 dateTime (USCDI+ Quality) When the procedure was first captured in the subject's record
URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-recorded
... basedOn Σ 0..* Reference(US Quality Core CarePlan | US Quality Core ServiceRequest) (USCDI) A request for this procedure
... status 1..1 code (USCDI+ Quality) (USCDI) preparation | in-progress | ​on-hold​ | stopped​ | completed | entered-in-error​ | unknown​
Binding: Non-Negative Event Status (required)
... statusReason 0..1 CodeableConcept (USCDI+ Quality) Reason for current status
... category 0..1 CodeableConcept Classification of the procedure
... code 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Identification of the procedure
... subject 1..1 Reference(US Quality Core Patient) (USCDI) Who the procedure was performed on
... performed[x] 0..1 dateTime, Period, string, Age, Range (USCDI+ Quality) (USCDI) When the procedure was performed
... performer
.... actor 1..1 Reference(US Quality Core Practitioner | US Quality Core Organization | US Quality Core Patient | US Quality Core RelatedPerson) The reference to the practitioner
... reasonCode 0..* CodeableConcept (USCDI+ Quality) Coded reason procedure performed
Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
... reasonReference 0..* Reference(US Quality Core Condition Encounter Diagnosis | US Quality Core Condition Problems Health Concerns | US Quality Core DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (USCDI+ Quality) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.status Base required Non-Negative Event Status 📦0.1.0 This IG
Procedure.reasonCode Base preferred Procedure Reason Codes 📦4.0.1 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
Constraints: us-core-7
... 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:recorded 0..1 dateTime (USCDI+ Quality) When the procedure was first captured in the subject's record
URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-recorded
... 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(US Quality Core CarePlan | US Quality Core ServiceRequest) (USCDI) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) (USCDI+ Quality) Part of referenced event
... status ?!SΣC 1..1 code (USCDI+ Quality) (USCDI) preparation | in-progress | ​on-hold​ | stopped​ | completed | entered-in-error​ | unknown​
Binding: Non-Negative Event Status (required)
... statusReason Σ 0..1 CodeableConcept (USCDI+ Quality) Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category Σ 0..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 (USCDI+ Quality) (USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) Who the procedure was performed on
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... performed[x] SΣC 0..1 (USCDI+ Quality) (USCDI) When the procedure was performed
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) 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(US Quality Core Practitioner | US Quality Core Organization | US Quality Core Patient | US Quality Core RelatedPerson) 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 Σ 0..* CodeableConcept (USCDI+ Quality) Coded reason procedure performed
Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(US Quality Core Condition Encounter Diagnosis | US Quality Core Condition Problems Health Concerns | US Quality Core DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (USCDI+ Quality) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... 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 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Procedure.status Base required Non-Negative Event Status 📦0.1.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦6.1.0 US Core v6.1
Procedure.performer.​function Base example Procedure Performer Role Codes 📦4.0.1 FHIR Std.
Procedure.reasonCode Base preferred Procedure Reason Codes 📦4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📦4.0.1 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📦4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Procedure If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Procedure 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Procedure If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Procedure If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Procedure A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-7 error Procedure Performed SHALL be present if the status is 'completed' or 'in-progress' (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from USCoreProcedureProfile

Summary

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
Constraints: us-core-7
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:recorded 0..1 dateTime (USCDI+ Quality) When the procedure was first captured in the subject's record
URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-recorded
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) (USCDI+ Quality) Part of referenced event
... status ?!SΣC 1..1 code (USCDI+ Quality) (USCDI) preparation | in-progress | ​on-hold​ | stopped​ | completed | entered-in-error​ | unknown​
Binding: Non-Negative Event Status (required)
... statusReason Σ 0..1 CodeableConcept (USCDI+ Quality) Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category Σ 0..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 (USCDI+ Quality) (USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) Who the procedure was performed on
... performed[x] SΣC 0..1 (USCDI+ Quality) (USCDI) When the procedure was performed
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... reasonCode Σ 0..* CodeableConcept (USCDI+ Quality) Coded reason procedure performed
Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(US Quality Core Condition Encounter Diagnosis | US Quality Core Condition Problems Health Concerns | US Quality Core DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (USCDI+ Quality) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required Non-Negative Event Status 📦0.1.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦6.1.0 US Core v6.1
Procedure.reasonCode Base preferred Procedure Reason Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Procedure If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Procedure 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Procedure If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Procedure If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Procedure A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-7 error Procedure Performed SHALL be present if the status is 'completed' or 'in-progress' (status='completed' or status='in-progress') implies performed.exists()

Differential View

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* USCoreProcedureProfile An action that is being or was performed on a patient
... implicitRules 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:recorded 0..1 dateTime (USCDI+ Quality) When the procedure was first captured in the subject's record
URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-recorded
... basedOn Σ 0..* Reference(US Quality Core CarePlan | US Quality Core ServiceRequest) (USCDI) A request for this procedure
... status 1..1 code (USCDI+ Quality) (USCDI) preparation | in-progress | ​on-hold​ | stopped​ | completed | entered-in-error​ | unknown​
Binding: Non-Negative Event Status (required)
... statusReason 0..1 CodeableConcept (USCDI+ Quality) Reason for current status
... category 0..1 CodeableConcept Classification of the procedure
... code 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Identification of the procedure
... subject 1..1 Reference(US Quality Core Patient) (USCDI) Who the procedure was performed on
... performed[x] 0..1 dateTime, Period, string, Age, Range (USCDI+ Quality) (USCDI) When the procedure was performed
... performer
.... actor 1..1 Reference(US Quality Core Practitioner | US Quality Core Organization | US Quality Core Patient | US Quality Core RelatedPerson) The reference to the practitioner
... reasonCode 0..* CodeableConcept (USCDI+ Quality) Coded reason procedure performed
Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
... reasonReference 0..* Reference(US Quality Core Condition Encounter Diagnosis | US Quality Core Condition Problems Health Concerns | US Quality Core DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (USCDI+ Quality) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.status Base required Non-Negative Event Status 📦0.1.0 This IG
Procedure.reasonCode Base preferred Procedure Reason Codes 📦4.0.1 FHIR Std.

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* USCoreProcedureProfile An action that is being or was performed on a patient
Constraints: us-core-7
... 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:recorded 0..1 dateTime (USCDI+ Quality) When the procedure was first captured in the subject's record
URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-recorded
... 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(US Quality Core CarePlan | US Quality Core ServiceRequest) (USCDI) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) (USCDI+ Quality) Part of referenced event
... status ?!SΣC 1..1 code (USCDI+ Quality) (USCDI) preparation | in-progress | ​on-hold​ | stopped​ | completed | entered-in-error​ | unknown​
Binding: Non-Negative Event Status (required)
... statusReason Σ 0..1 CodeableConcept (USCDI+ Quality) Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category Σ 0..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 (USCDI+ Quality) (USCDI) Identification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) Who the procedure was performed on
... encounter Σ 0..1 Reference(Encounter) Encounter created as part of
... performed[x] SΣC 0..1 (USCDI+ Quality) (USCDI) When the procedure was performed
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) 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(US Quality Core Practitioner | US Quality Core Organization | US Quality Core Patient | US Quality Core RelatedPerson) 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 Σ 0..* CodeableConcept (USCDI+ Quality) Coded reason procedure performed
Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(US Quality Core Condition Encounter Diagnosis | US Quality Core Condition Problems Health Concerns | US Quality Core DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (USCDI+ Quality) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... 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 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Procedure.status Base required Non-Negative Event Status 📦0.1.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦6.1.0 US Core v6.1
Procedure.performer.​function Base example Procedure Performer Role Codes 📦4.0.1 FHIR Std.
Procedure.reasonCode Base preferred Procedure Reason Codes 📦4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📦4.0.1 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📦4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Procedure If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Procedure 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 contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Procedure If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Procedure If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Procedure A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-7 error Procedure Performed SHALL be present if the status is 'completed' or 'in-progress' (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from USCoreProcedureProfile

Summary

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron