US Core Implementation Guide
7.0.0 - CI Build United States of America flag

US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Resource Profile: US Core Procedure Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure Version: 7.0.0
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreProcedureProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.42.46

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Procedure Profile is based upon the core FHIR Procedure Resource and meets the U.S. Core Data for Interoperability (USCDI) ‘Procedures’ requirements. This profile sets minimum expectations for the Procedure resource to record, search, and fetch procedures associated with a patient to promote interoperability and adoption through common implementation. It identifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains the way the elements are used when using this profile. It provides the floor for standards development for specific use cases.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for procedures performed on a Patient
  • Record or update a procedure performed on a Patient

Mandatory and Must Support Data Elements

The following data-elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Procedure Must Have:

  1. a status
  2. a code that identifies the type of procedure performed on the patient
  3. a patient
  4. when the procedure was performed*

*This elements have the following constraints: SHALL be present if status is ‘completed’ or ‘in-progress’.

Each Procedure Must Support:

  1. the encounter associated with the procedure

Additional USCDI Requirements:

This Additional USCDI Requirements element is not Mandatory or Must Support but is required for ONC Health IT certification testing and is included in the formal definition of the profile and the Procedure examples.

  1. a reason or indication for referral or consultation*

*see guidance below

Profile Specific Implementation Guidance:

  • Procedure codes can be taken from SNOMED-CT, CPT, HCPCS II, ICD-10-PCS, CDT. LOINC.
    • Only LOINC concepts that reflect actual procedures SHOULD be used
  • A procedure including an implantable device SHOULD use Procedure.focalDevice with a reference to the US Core Implantable Device Profile.
  • See the Screening and Assessments guidance page for more information when exchanging Social Determinants of Health (SDOH) Procedures

  • *The Reason or justification for a referral or consultation is communicated through:
    1. Procedure.basedOn that links the Procedure to the US Core ServiceRequest Profile that includes either ServiceRequest.reasonCode or ServiceRequest.reasonReference
      • ServiceRequest.reasonCode and ServiceRequest.reasonReference are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
      • As documented here, when using ServiceRequest.reasonReference, the referenced resources SHOULD be a US Core Profile.
    2. Procedure.reasonCode or Procedure.reasonReference when the Procedure does not have an associated ServiceRequest.
      • Although both Procedure.reasonCode and Procedure.reasonReference are marked as Additional USCDI Requirements. The certifying server system is not required to support both but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
      • As documented here, when using Procedure.reasonReference, the referenced resources SHOULD be a US Core Profile.

    Servers and Clients SHALL support options 1 and 2 as Additional USCDI Requirements. Depending on the procedure being documented, a server will select option 1 or 2.

Usage:

Changes since version 7.0.0-ballot:

  • The resource metadata has changed (description)
  • The data elements list has changed
  • One or more text definitions, invariants or bindings have changed
  • Formal Views of Profile Content

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

    This structure is derived from Procedure

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C0..*ProcedureAn action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... basedOn 0..*Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
    ... status SC1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... code S1..1CodeableConceptIdentification of the procedure
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

    ... subject S1..1Reference(US Core Patient Profile S | Group)Who the procedure was performed on
    ... encounter S0..1Reference(US Core Encounter Profile)Encounter associated with the procedure
    ... performed[x] SC0..1When the procedure was performed
    .... performedDateTimedateTime S
    .... performedPeriodPeriod
    .... performedStringstring
    .... performedAgeAge
    .... performedRangeRange
    ... reasonCode 0..*CodeableConcept𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed
    Binding: US Core Condition Codes (extensible)
    ... reasonReference 0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.codeextensibleUSCoreProcedureCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    from this IG
    Procedure.reasonCodeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
    : (status='completed' or status='in-progress') implies performed.exists()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C0..*ProcedureAn action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... basedOn Σ0..*Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
    ... status ?!SΣC1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... code SΣ1..1CodeableConceptIdentification of the procedure
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

    ... subject SΣ1..1Reference(US Core Patient Profile)Who the procedure was performed on
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter associated with the procedure
    ... performed[x] SΣC0..1When the procedure was performed
    .... performedDateTimedateTime
    ... reasonCode Σ0..*CodeableConcept𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed
    Binding: US Core Condition Codes (extensible)
    ... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.codeextensibleUSCoreProcedureCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    from this IG
    Procedure.reasonCodeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
    : (status='completed' or status='in-progress') implies performed.exists()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C0..*ProcedureAn action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... text 0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... extension 0..*ExtensionAdditional content defined by implementations
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier Σ0..*IdentifierExternal Identifiers for this procedure
    ... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
    ... instantiatesUri Σ0..*uriInstantiates external protocol or definition
    ... basedOn Σ0..*Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
    ... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
    ... status ?!SΣC1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... statusReason Σ0..1CodeableConceptReason for current status
    Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

    ... category Σ0..1CodeableConceptClassification of the procedure
    Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

    ... code SΣ1..1CodeableConceptIdentification of the procedure
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

    ... subject SΣ1..1Reference(US Core Patient Profile S | Group)Who the procedure was performed on
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter associated with the procedure
    ... performed[x] SΣC0..1When the procedure was performed
    .... performedDateTimedateTime S
    .... performedPeriodPeriod
    .... performedStringstring
    .... performedAgeAge
    .... performedRangeRange
    ... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
    ... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
    ... performer Σ0..*BackboneElementThe people who performed the procedure
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... function Σ0..1CodeableConceptType of performance
    Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

    .... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
    .... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
    ... location Σ0..1Reference(Location)Where the procedure happened
    ... reasonCode Σ0..*CodeableConcept𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed
    Binding: US Core Condition Codes (extensible)
    ... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
    ... bodySite Σ0..*CodeableConceptTarget body sites
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


    ... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
    Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


    ... note 0..*AnnotationAdditional information about the procedure
    ... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... action 0..1CodeableConceptKind of change to device
    Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

    .... manipulated 1..1Reference(Device)Device that was changed
    ... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
    ... usedCode 0..*CodeableConceptCoded items used during the procedure
    Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
    http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
    from the FHIR Standard
    Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-category
    from the FHIR Standard
    Procedure.codeextensibleUSCoreProcedureCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    from this IG
    Procedure.performer.functionexampleProcedurePerformerRoleCodes
    http://hl7.org/fhir/ValueSet/performer-role
    from the FHIR Standard
    Procedure.reasonCodeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG
    Procedure.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-outcome
    from the FHIR Standard
    Procedure.complicationexampleCondition/Problem/DiagnosisCodes
    http://hl7.org/fhir/ValueSet/condition-code
    from the FHIR Standard
    Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-followup
    from the FHIR Standard
    Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
    http://hl7.org/fhir/ValueSet/device-action
    from the FHIR Standard
    Procedure.usedCodeexampleFHIRDeviceTypes
    http://hl7.org/fhir/ValueSet/device-kind
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    us-core-7errorProcedurePerformed 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 Procedure

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C0..*ProcedureAn action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... basedOn 0..*Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
    ... status SC1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... code S1..1CodeableConceptIdentification of the procedure
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

    ... subject S1..1Reference(US Core Patient Profile S | Group)Who the procedure was performed on
    ... encounter S0..1Reference(US Core Encounter Profile)Encounter associated with the procedure
    ... performed[x] SC0..1When the procedure was performed
    .... performedDateTimedateTime S
    .... performedPeriodPeriod
    .... performedStringstring
    .... performedAgeAge
    .... performedRangeRange
    ... reasonCode 0..*CodeableConcept𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed
    Binding: US Core Condition Codes (extensible)
    ... reasonReference 0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.codeextensibleUSCoreProcedureCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    from this IG
    Procedure.reasonCodeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
    : (status='completed' or status='in-progress') implies performed.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C0..*ProcedureAn action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... basedOn Σ0..*Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
    ... status ?!SΣC1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... code SΣ1..1CodeableConceptIdentification of the procedure
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

    ... subject SΣ1..1Reference(US Core Patient Profile)Who the procedure was performed on
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter associated with the procedure
    ... performed[x] SΣC0..1When the procedure was performed
    .... performedDateTimedateTime
    ... reasonCode Σ0..*CodeableConcept𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed
    Binding: US Core Condition Codes (extensible)
    ... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.codeextensibleUSCoreProcedureCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    from this IG
    Procedure.reasonCodeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
    : (status='completed' or status='in-progress') implies performed.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure C0..*ProcedureAn action that is being or was performed on a patient
    us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
    ... id Σ0..1idLogical id of this artifact
    ... meta Σ0..1MetaMetadata about the resource
    ... implicitRules ?!Σ0..1uriA set of rules under which this content was created
    ... language 0..1codeLanguage of the resource content
    Binding: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguagesMax Binding
    ... text 0..1NarrativeText summary of the resource, for human interpretation
    ... contained 0..*ResourceContained, inline Resources
    ... extension 0..*ExtensionAdditional content defined by implementations
    ... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
    ... identifier Σ0..*IdentifierExternal Identifiers for this procedure
    ... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
    ... instantiatesUri Σ0..*uriInstantiates external protocol or definition
    ... basedOn Σ0..*Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
    ... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
    ... status ?!SΣC1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    Binding: EventStatus (required)
    ... statusReason Σ0..1CodeableConceptReason for current status
    Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

    ... category Σ0..1CodeableConceptClassification of the procedure
    Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

    ... code SΣ1..1CodeableConceptIdentification of the procedure
    Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

    ... subject SΣ1..1Reference(US Core Patient Profile S | Group)Who the procedure was performed on
    ... encounter SΣ0..1Reference(US Core Encounter Profile)Encounter associated with the procedure
    ... performed[x] SΣC0..1When the procedure was performed
    .... performedDateTimedateTime S
    .... performedPeriodPeriod
    .... performedStringstring
    .... performedAgeAge
    .... performedRangeRange
    ... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
    ... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
    ... performer Σ0..*BackboneElementThe people who performed the procedure
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... function Σ0..1CodeableConceptType of performance
    Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

    .... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
    .... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
    ... location Σ0..1Reference(Location)Where the procedure happened
    ... reasonCode Σ0..*CodeableConcept𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed
    Binding: US Core Condition Codes (extensible)
    ... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
    ... bodySite Σ0..*CodeableConceptTarget body sites
    Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


    ... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
    Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


    ... note 0..*AnnotationAdditional information about the procedure
    ... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
    .... id 0..1stringUnique id for inter-element referencing
    .... extension 0..*ExtensionAdditional content defined by implementations
    .... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
    .... action 0..1CodeableConceptKind of change to device
    Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

    .... manipulated 1..1Reference(Device)Device that was changed
    ... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
    ... usedCode 0..*CodeableConceptCoded items used during the procedure
    Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status
    from the FHIR Standard
    Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
    http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
    from the FHIR Standard
    Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-category
    from the FHIR Standard
    Procedure.codeextensibleUSCoreProcedureCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
    from this IG
    Procedure.performer.functionexampleProcedurePerformerRoleCodes
    http://hl7.org/fhir/ValueSet/performer-role
    from the FHIR Standard
    Procedure.reasonCodeextensibleUSCoreConditionCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
    from this IG
    Procedure.bodySiteexampleSNOMEDCTBodyStructures
    http://hl7.org/fhir/ValueSet/body-site
    from the FHIR Standard
    Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-outcome
    from the FHIR Standard
    Procedure.complicationexampleCondition/Problem/DiagnosisCodes
    http://hl7.org/fhir/ValueSet/condition-code
    from the FHIR Standard
    Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-followup
    from the FHIR Standard
    Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
    http://hl7.org/fhir/ValueSet/device-action
    from the FHIR Standard
    Procedure.usedCodeexampleFHIRDeviceTypes
    http://hl7.org/fhir/ValueSet/device-kind
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
    : (status='completed' or status='in-progress') implies performed.exists()

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:


    Quick Start


    Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

    • See the Scopes Format section for a description of the SMART scopes syntax.
    • See the Search Syntax section for a description of the US Core search syntax.
    • See the General Requirements section for additional rules and expectations when a server requires status parameters.
    • See the General Guidance section for additional guidance on searching for multiple <patient user system>s.

    US Core Scopes

    Servers providing access to procedure data SHALL support these US Core SMART Scopes:

    Mandatory Search Parameters:

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

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

      GET [base]/Procedure?patient={Type/}[id]

      Example:

      1. GET [base]/Procedure?patient=1291938

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

    2. SHALL support searching using the combination of the patient and date search parameters:

      • including support for these date comparators: gt,lt,ge,le
      • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

      GET [base]/Procedure?patient={Type/}[id]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/Procedure?patient=1137192&date=ge2019-01-14

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

    Optional Search Parameters:

    The following search parameter combinations SHOULD be supported:

    1. SHOULD support searching using the combination of the patient and status search parameters:
      • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

      GET [base]/Procedure?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

      Example:

      1. GET [base]/Procedure?patient=1137192&status=completed

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

    2. SHOULD support searching using the combination of the patient and code and date search parameters:
      • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
      • including support for these date comparators: gt,lt,ge,le
      • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

      GET [base]/Procedure?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/Procedure?patient=1137192&date=ge2019-01-14T00:00:00Z&code=http://snomed.info/sct|35637008

      Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date and procedure code(s). SHOULD support search by multiple codes. (how to search by reference and how to search by token and how to search by date)