US Core Implementation Guide
10.0.0-ballot - STU 10 Ballot
US Core Implementation Guide
10.0.0-ballot - STU 10 Ballot
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 10.0.0-ballot 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
| Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure | Version: 10.0.0-ballot | |||
| Standards status: Trial-use | Maturity Level: 5 | Computable Name: USCoreProcedureProfile | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.53 | ||||
The US Core Procedure Profile inherits from the FHIR Procedure resource; refer to it for scope and usage definitions. This profile meets the requirements of the U.S. Core Data for Interoperability (USCDI) Procedures Data Class. It sets minimum expectations for the Procedure resource to record, search, and fetch procedure information associated with a patient. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.
Example Usage Scenarios:
The following are example usage scenarios for this profile:
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:
Each Procedure Must Support:
Additional USCDI Requirements:
These Additional USCDI Requirements elements are not Mandatory or Must Support but are required for ONC Health IT certification testing and are included in the formal definition of the profile and the Procedure examples.
1,2,3,4,5,6 see guidance below
This section provides detailed implementation guidance for the US Core Profile to support implementation and certification.
Procedure.statusReason communicates why the procedure was not performed, such as patient refusal. Note that this binding is provisional, pending the review of the terminology aligned with the HL7 FHIR US Quality Core Implementation Guide.Procedure.performed[x] is ambiguous when no procedure took place.Procedure.performed is mandatory if Procedure.status is "completed" or "in-progress".Procedure.focalDevice referencing the US Core Device Profile.§Procedure.basedOn linking the Procedure to the US Core ServiceRequest Profile that includes either ServiceRequest.reasonCode or ServiceRequest.reasonReference. When the Procedure does not have an associated ServiceRequest, it is communicated through the US Core Procedure Profile's Procedure.reasonCode or Procedure.reasonReference. Depending on the procedure being documented, a Server will select the appropriate Profile to use.
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.§
Procedure.reasonReference:
Procedure.reasonReference.§ Clients SHALL support all target resources in Procedure.reasonReference.§3The profile elements Procedure.asserter and Procedure.performer.actor communicate the individual level provenance author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.
For the USCDI Adverse Events Data Class, a procedure can be the intervention a change in a patient condition is associated with, recording the change that the USCDI Adverse Event Condition describes. Adverse events are recorded as ordinary clinical events and are not tagged as adverse events; see the Adverse Events: Clinical Records and Patient Safety Reporting page.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 9.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  Procedure |
C | 0..* | Procedure | An action that is being or was performed on a patient Constraints: us-core-7 |
  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 | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: When the procedure was first captured in the patient's record URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1 | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
 basedOn |
0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure | |
| status |
C | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
 statusReason |
0..1 | CodeableConcept | Reason the procedure was not performed Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible) | |
| code |
1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | |
| subject |
1..1 | Reference(US Core Patient Profile | Group) | Who the procedure was performed on | |
| encounter |
0..1 | Reference(US Core Encounter Profile) | Encounter associated with the procedure | |
 performed[x] |
C | 0..1 | When the procedure was performed | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
 performedRange |
Range | |||
| performer |
0..* | BackboneElement | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The people who performed the procedure | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| actor |
1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile | US Core Device Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The reference to the practitioner | |
| reasonCode |
0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 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 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📦4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | extensible | Procedure Not Performed Reason (SNOMED-CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | US Core Procedure Codes | 📦10.0.0-ballot | This IG |
| Procedure.reasonCode | Base | extensible | US Core Condition Codes | 📦10.0.0-ballot | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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 Procedure
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
C | 0..* | Procedure | An action that is being or was performed on a patient Constraints: us-core-7 |
| Slices for extension |
Content/Rules for all slices | |||
| extension:recorded |
0..1 | dateTime | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: When the procedure was first captured in the patient's record URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded | |
| basedOn |
0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure | |
 status |
C | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason |
0..1 | CodeableConcept | Reason the procedure was not performed Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible) | |
| code |
1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | |
| subject |
1..1 | Reference(US Core Patient Profile | Group) | Who the procedure was performed on | |
| encounter |
0..1 | Reference(US Core Encounter Profile) | Encounter associated with the procedure | |
| performed[x] |
C | 0..1 | When the procedure was performed | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| performer |
0..* | BackboneElement | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The people who performed the procedure | |
| actor |
1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile | US Core Device Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The reference to the practitioner | |
| reasonCode |
0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 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 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📦4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | extensible | Procedure Not Performed Reason (SNOMED-CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | US Core Procedure Codes | 📦10.0.0-ballot | This IG |
| Procedure.reasonCode | Base | extensible | US Core Condition Codes | 📦10.0.0-ballot | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | Procedure | An action that is being or was performed on a patient Constraints: us-core-7 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation 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 | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: When the procedure was first captured in the patient's record URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1 | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | External Identifiers for this procedure | |||||
| instantiatesCanonical |
0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | |||||
| instantiatesUri |
0..* | uri | Instantiates external protocol or definition | |||||
| basedOn |
0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure | |||||
| partOf |
0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | |||||
| status |
C | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason |
0..1 | CodeableConcept | Reason the procedure was not performed Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible) | |||||
| category |
0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | |||||
| code |
1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | |||||
| subject |
1..1 | Reference(US Core Patient Profile | Group) | Who the procedure was performed on | |||||
| encounter |
0..1 | Reference(US Core Encounter Profile) | Encounter associated with the procedure | |||||
| performed[x] |
C | 0..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| recorder |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |||||
| asserter |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |||||
| performer |
0..* | BackboneElement | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| function |
0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | |||||
| actor |
1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile | US Core Device Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The reference to the practitioner | |||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location |
0..1 | Reference(Location) | Where the procedure happened | |||||
| reasonCode |
0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 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 | |||||
| bodySite |
0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
| outcome |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
1..1 | Reference(Device) | Device that was changed | |||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Id | Grade | Path(s) | Description | Expression |
| 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 Procedure
Summary
Mandatory: 1 element
Must-Support: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 5
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
C | 0..* | Procedure | An action that is being or was performed on a patient Constraints: us-core-7 |
| 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 | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: When the procedure was first captured in the patient's record URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| basedOn |
0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure | |
| status |
C | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason |
0..1 | CodeableConcept | Reason the procedure was not performed Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible) | |
| code |
1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | |
| subject |
1..1 | Reference(US Core Patient Profile | Group) | Who the procedure was performed on | |
| encounter |
0..1 | Reference(US Core Encounter Profile) | Encounter associated with the procedure | |
| performed[x] |
C | 0..1 | When the procedure was performed | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| performer |
0..* | BackboneElement | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The people who performed the procedure | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| actor |
1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile | US Core Device Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The reference to the practitioner | |
| reasonCode |
0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 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 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📦4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | extensible | Procedure Not Performed Reason (SNOMED-CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | US Core Procedure Codes | 📦10.0.0-ballot | This IG |
| Procedure.reasonCode | Base | extensible | US Core Condition Codes | 📦10.0.0-ballot | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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 Procedure
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
C | 0..* | Procedure | An action that is being or was performed on a patient Constraints: us-core-7 |
| Slices for extension |
Content/Rules for all slices | |||
| extension:recorded |
0..1 | dateTime | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: When the procedure was first captured in the patient's record URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded | |
| basedOn |
0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure | |
| status |
C | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason |
0..1 | CodeableConcept | Reason the procedure was not performed Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible) | |
| code |
1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | |
| subject |
1..1 | Reference(US Core Patient Profile | Group) | Who the procedure was performed on | |
| encounter |
0..1 | Reference(US Core Encounter Profile) | Encounter associated with the procedure | |
| performed[x] |
C | 0..1 | When the procedure was performed | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| performer |
0..* | BackboneElement | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The people who performed the procedure | |
| actor |
1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile | US Core Device Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The reference to the practitioner | |
| reasonCode |
0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 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 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📦4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | extensible | Procedure Not Performed Reason (SNOMED-CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code | Base | extensible | US Core Procedure Codes | 📦10.0.0-ballot | This IG |
| Procedure.reasonCode | Base | extensible | US Core Condition Codes | 📦10.0.0-ballot | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | Procedure | An action that is being or was performed on a patient Constraints: us-core-7 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation 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 | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: When the procedure was first captured in the patient's record URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1 | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | External Identifiers for this procedure | |||||
| instantiatesCanonical |
0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | |||||
| instantiatesUri |
0..* | uri | Instantiates external protocol or definition | |||||
| basedOn |
0..* | Reference(US Core CarePlan Profile | US Core ServiceRequest Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure | |||||
| partOf |
0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | |||||
| status |
C | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason |
0..1 | CodeableConcept | Reason the procedure was not performed Binding: ProcedureNotPerformedReason(SNOMED-CT) (extensible) | |||||
| category |
0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | |||||
| code |
1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | |||||
| subject |
1..1 | Reference(US Core Patient Profile | Group) | Who the procedure was performed on | |||||
| encounter |
0..1 | Reference(US Core Encounter Profile) | Encounter associated with the procedure | |||||
| performed[x] |
C | 0..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| recorder |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |||||
| asserter |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |||||
| performer |
0..* | BackboneElement | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| function |
0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | |||||
| actor |
1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile | US Core Patient Profile | US Core RelatedPerson Profile | US Core Device Profile) | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: The reference to the practitioner | |||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location |
0..1 | Reference(Location) | Where the procedure happened | |||||
| reasonCode |
0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 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 | |||||
| bodySite |
0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
| outcome |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
1..1 | Reference(Device) | Device that was changed | |||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Id | Grade | Path(s) | Description | Expression |
| 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 Procedure
Summary
Mandatory: 1 element
Must-Support: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 5
Other representations of profile: CSV, Excel, Schematron
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.
Servers providing access to procedure data SHALL support these US Core SMART Scopes:
<patient|user|system>/Procedure.rs §The following search parameters and search parameter combinations SHALL be supported:
SHALL support searching for all procedures for a patient using the patient search parameter
GET [base]/Procedure?patient={Patient/}[id]
Example:
- GET [base]/Procedure?patient=Patient/1137192
Implementation Notes: Fetches a bundle of all US Core Procedure Profile resources for the specified patient ( see how to search by reference).
SHALL support searching for all procedures for a patient for a given status (for example all completed procedures) using the combination of the patient and status search parameters
status (e.g.status={system|}[code],{system|}[code],...)GET [base]/Procedure?patient={Patient/}[id]&status={system|}[search_code]{,{system|}[code],...}
Example:
- GET [base]/Procedure?patient=Patient/1137192&status=completed
Implementation Notes: Fetches a bundle of all US Core Procedure Profile resources for the specified patient and status ( see how to search by reference and how to search by token).
SHALL support searching for all procedures for a patient by date using the combination of the patient and date search parameters
Including optional support for AND search on date (e.g.date=[date]&date=[date]&...)
Including support for these date comparators: "gt", "lt", "ge", "le"
GET [base]/Procedure?patient={Patient/}[id]&date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}
Example:
- GET [base]/Procedure?patient=Patient/1137192&date=ge2019-01-14
Implementation Notes: Fetches a bundle of all US Core Procedure Profile resources for the specified patient and date ( see how to search by reference and how to search by date).
The following search parameters and search parameter combinations SHOULD be supported
SHOULD support searching for procedures for a patient by code and date using the combination of the patient and code and date search parameters
Including optional support OR search on code (e.g.code={system|}[code],{system|}[code],...)
Including optional support for AND search on date (e.g.date=[date]&date=[date]&...)
Including support for these date comparators: "gt", "lt", "ge", "le"
GET [base]/Procedure?patient={Patient/}[id]&code={system|}[search_code]{,{system|}[code],...}&date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}
Example:
- GET [base]/Procedure?patient=Patient/1137192&date=ge2019-01-14T00:00:00Z&code=http://snomed.info/sct|35637008
Implementation Notes: Fetches a bundle of all US Core Procedure Profile resources for the specified patient and date and procedure code(s). SHOULD support search by multiple codes. ( see how to search by reference and how to search by token and how to search by date).
IG © 2027+ HL7 International / Cross-Group Projects. Package hl7.fhir.us.core#10.0.0-ballot based on FHIR 4.0.1. Generated 2026-10-22
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change