CA Baseline Procedure Profile

This profile sets minimum expectations for the Procedure resource to record, search and fetch current or historical procedures performed on or for a patient. It identifies which elements and value sets SHALL be present in the resource when using this profile.

This profile defines localization concepts for use in an Canadian context.

Mandatory Data Elements

All elements or attributes defined in FHIR have cardinality as part of their definition - a minimum number of required appearances and a maximum number.

Most elements in FHIR specification have a minimum cardinality of 0, which means that they may be missing from a resource when it is exchanged between systems.

Required elements:

• status specifying the state of the procedure (required in the base specification)
• code to classify the procedure that is performed
• reference to a subject
• date procedure was performed

Must Support Data Elements

Some elements are labeled as MustSupport meaning that implementations that produce or consume resources SHALL provide “support” for the element in some meaningful way (see Must Support definition).

Following elements are marked as Must Support in the Procedure profile to aid record matching in databases with many pediatric records.

Must Support elements:

• status
• code
• reference to a subject
• performed date
• body site

Usage Note

This Procedure profile is used to provide summary information about the occurrence of current or historical procedures performed on or for a patient, and is not intended to provide real-time snapshots of a procedure as it unfolds. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise and so on.

A slice for absentOrUnknownProcedure comes from the IPS-UV specification and has been socialized in the profile as a way to represent a standard set of codes for identifying absent or unknown procedures. While the profile expects that a procedure.code be present (cardinality of 1..1) the use of the slice is entirely optional.

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

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	Procedure Profile
partOf		0..*	Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile)	Part of referenced event
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Slices for code	S	1..1	CodeableConcept	Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers.
code:absentOrUnknownProcedure		0..1	CodeableConcept	Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures
subject	S	1..1	Reference(Patient Profile)	Who the procedure was performed on
encounter		0..1	Reference(Encounter Profile)	Encounter created as part of
performed[x]	S	1..1		When the procedure was performed
performed[x]:All Types				Content/Rules for all Types
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason		0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder		0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Who recorded the procedure
asserter		0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Person who asserts this procedure
performer
actor		1..1	Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile | RelatedPerson | Device Profile (Implantable))	The reference to the practitioner
location		0..1	Reference(Location Profile)	Where the procedure happened
reasonReference		0..*	Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document)	The justification that the procedure was performed
complicationDetail		0..*	Reference(Condition Profile)	A condition that is a result of the procedure
usedReference		0..*	Reference(Device Profile (Implantable) | Medication Profile | Substance)	Items used during procedure
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	preferred	https://fhir.infoway-inforoute.ca/ValueSet/interventioncode https://fhir.infoway-inforoute.ca/ValueSet/interventioncode
Procedure.code:absentOrUnknownProcedure	required	http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	Procedure Profile
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
partOf	Σ	0..*	Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile)	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.
Slices for code	SΣ	1..1	CodeableConcept	Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers.
code:absentOrUnknownProcedure	Σ	0..1	CodeableConcept	Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures
subject	SΣ	1..1	Reference(Patient Profile)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter Profile)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performed[x]:All Types				Content/Rules for all Types
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason		0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Person who asserts this procedure
location	Σ	0..1	Reference(Location Profile)	Where the procedure happened
reasonReference	Σ	0..*	Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document)	The justification that the procedure was performed
complicationDetail		0..*	Reference(Condition Profile)	A condition that is a result of the procedure
usedReference		0..*	Reference(Device Profile (Implantable) | Medication Profile | Substance)	Items used during procedure
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.code	preferred	https://fhir.infoway-inforoute.ca/ValueSet/interventioncode https://fhir.infoway-inforoute.ca/ValueSet/interventioncode
Procedure.code:absentOrUnknownProcedure	required	http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	Procedure Profile
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
extension		0..*	Extension	Additional content defined by implementations
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 Profile | Observation Profile (General Use) | MedicationAdministration Profile)	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	Σ	0..1	CodeableConcept	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.
Slices for code	SΣ	1..1	CodeableConcept	Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers.
code:absentOrUnknownProcedure	Σ	0..1	CodeableConcept	Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures
subject	SΣ	1..1	Reference(Patient Profile)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter Profile)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performed[x]:All Types				Content/Rules for all Types
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason		0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	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 Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile | RelatedPerson | Device Profile (Implantable))	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location Profile)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document)	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 Profile)	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 Profile (Implantable) | Medication Profile | 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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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	preferred	https://fhir.infoway-inforoute.ca/ValueSet/interventioncode https://fhir.infoway-inforoute.ca/ValueSet/interventioncode
Procedure.code:absentOrUnknownProcedure	required	http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips
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	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
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
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()

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	Procedure Profile
partOf		0..*	Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile)	Part of referenced event
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Slices for code	S	1..1	CodeableConcept	Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers.
code:absentOrUnknownProcedure		0..1	CodeableConcept	Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures
subject	S	1..1	Reference(Patient Profile)	Who the procedure was performed on
encounter		0..1	Reference(Encounter Profile)	Encounter created as part of
performed[x]	S	1..1		When the procedure was performed
performed[x]:All Types				Content/Rules for all Types
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason		0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder		0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Who recorded the procedure
asserter		0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Person who asserts this procedure
performer
actor		1..1	Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile | RelatedPerson | Device Profile (Implantable))	The reference to the practitioner
location		0..1	Reference(Location Profile)	Where the procedure happened
reasonReference		0..*	Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document)	The justification that the procedure was performed
complicationDetail		0..*	Reference(Condition Profile)	A condition that is a result of the procedure
usedReference		0..*	Reference(Device Profile (Implantable) | Medication Profile | Substance)	Items used during procedure
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	preferred	https://fhir.infoway-inforoute.ca/ValueSet/interventioncode https://fhir.infoway-inforoute.ca/ValueSet/interventioncode
Procedure.code:absentOrUnknownProcedure	required	http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	Procedure Profile
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
partOf	Σ	0..*	Reference(Procedure Profile | Observation Profile (General Use) | MedicationAdministration Profile)	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.
Slices for code	SΣ	1..1	CodeableConcept	Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers.
code:absentOrUnknownProcedure	Σ	0..1	CodeableConcept	Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures
subject	SΣ	1..1	Reference(Patient Profile)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter Profile)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performed[x]:All Types				Content/Rules for all Types
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason		0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Person who asserts this procedure
location	Σ	0..1	Reference(Location Profile)	Where the procedure happened
reasonReference	Σ	0..*	Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document)	The justification that the procedure was performed
complicationDetail		0..*	Reference(Condition Profile)	A condition that is a result of the procedure
usedReference		0..*	Reference(Device Profile (Implantable) | Medication Profile | Substance)	Items used during procedure
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.code	preferred	https://fhir.infoway-inforoute.ca/ValueSet/interventioncode https://fhir.infoway-inforoute.ca/ValueSet/interventioncode
Procedure.code:absentOrUnknownProcedure	required	http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	Procedure Profile
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
extension		0..*	Extension	Additional content defined by implementations
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 Profile | Observation Profile (General Use) | MedicationAdministration Profile)	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	Σ	0..1	CodeableConcept	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.
Slices for code	SΣ	1..1	CodeableConcept	Identification of the procedure Slice: Unordered, Open by pattern:$this Binding: https://fhir.infoway-inforoute.ca/ValueSet/interventioncode (preferred): Extensional Subset of SNOMED CT and SNOMED CT CA Extension Codes to describe Services/Activities performed by Primary Health Care Providers.
code:absentOrUnknownProcedure	Σ	0..1	CodeableConcept	Code for absent problem or for unknown procedure Binding: http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips (required): A code to identify absent or unknown procedures
subject	SΣ	1..1	Reference(Patient Profile)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter Profile)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performed[x]:All Types				Content/Rules for all Types
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason		0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient Profile | RelatedPerson | Practitioner Profile (General) | PractitionerRole Profile (General))	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 Profile (General) | PractitionerRole Profile (General) | Organization Profile | Patient Profile | RelatedPerson | Device Profile (Implantable))	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location Profile)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(Condition Profile | Observation Profile (General Use) | Procedure Profile | DiagnosticReport Profile for Results Reporting | DocumentReference Profile for metadata about the document)	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 Profile)	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 Profile (Implantable) | Medication Profile | 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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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	preferred	https://fhir.infoway-inforoute.ca/ValueSet/interventioncode https://fhir.infoway-inforoute.ca/ValueSet/interventioncode
Procedure.code:absentOrUnknownProcedure	required	http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips
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	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
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
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()

This structure is derived from Procedure

Code

The Procedure.code element is used to specify a procedure that is performed.

The Procedure.code element is CodeableConcept data type meaning that more than one Coding sub-elements can be present. One of these Coding sub-elements MAY use InterventionCodeSubsetOperatingRoomProcedure value set from Canada Health Infoway.

Use text if the exact nature of the procedure cannot be coded (e.g. “Laparoscopic Appendectomy”).