Common Data Models Harmonization
1.0.0 - STU 1 Publication

Common Data Models Harmonization, published by HL7 International - Biomedical Research and Regulation Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/cdmh/ and changes regularly. See the Directory of published versions

Resource Profile: CdmhProcedure

Defining URL:http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-procedure
Version:1.0.0
Name:CdmhProcedure
Title:CDMH Procedure
Status:Draft as of 9/1/19
Definition:

This is the Procedure Resource profile for the IG.

Publisher:HL7 International - Biomedical Research and Regulation Work Group
Copyright:

Used by permission of HL7, all rights reserved Creative Commons License

Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-procedure

Formal Views of Profile Content

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

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*USCoreProcedureProfileCDMH Procedure
... code S1..1CodeableConceptIdentification of the procedure
.... cdmh-pcornet-px-source S0..1codePCORNet Procedure Information Source
URL: http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-pcornet-px-source
Binding: PCORNet Information Source HC Subtype (extensible): Procedure Information Source subtypes within a healthcare organization.

... subject S1..1Reference(CDMH Patient)Who the procedure was performed on
... encounter S0..1Reference(CDMH Encounter)Encounter created as part of
.... actor S1..1Reference(US Core Practitioner Profile)The reference to the practitioner
... focalDevice S0..*BackboneElementManipulated, implanted, or removed device
.... manipulated S1..1Reference(US Core Implantable Device Profile)Device that was changed
... usedReference S0..*Reference(US Core Implantable Device Profile)Items used during procedure
... usedCode S0..*CodeableConceptCoded items used during the procedure

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*USCoreProcedureProfileCDMH Procedure
... id Σ0..1stringLogical 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)
Max Binding: AllLanguages: A human language.

... 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(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..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

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... cdmh-pcornet-px-source S0..1codePCORNet Procedure Information Source
URL: http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-pcornet-px-source
Binding: PCORNet Information Source HC Subtype (extensible): Procedure Information Source subtypes within a healthcare organization.


.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(CDMH Patient)Who the procedure was performed on
... encounter SΣ0..1Reference(CDMH Encounter)Encounter created as part of
... performed[x] SΣ1..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 SΣ0..*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 SΣ1..1Reference(US Core Practitioner Profile)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..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was 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 S0..*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 S1..1Reference(US Core Implantable Device Profile)Device that was changed
... usedReference S0..*Reference(US Core Implantable Device Profile)Items used during procedure
... usedCode S0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*USCoreProcedureProfileCDMH Procedure
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
... code Σ1..1CodeableConceptIdentification of the procedure
Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure

.... cdmh-pcornet-px-source 0..1codePCORNet Procedure Information Source
URL: http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-pcornet-px-source
Binding: PCORNet Information Source HC Subtype (extensible): Procedure Information Source subtypes within a healthcare organization.


... subject Σ1..1Reference(CDMH Patient)Who the procedure was performed on
... performed[x] Σ1..1When the procedure was performed
.... performedDateTimedateTime
... performer Σ0..*BackboneElementThe people who performed the procedure
.... actor Σ1..1Reference(US Core Practitioner Profile)The reference to the practitioner
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... manipulated 1..1Reference(US Core Implantable Device Profile)Device that was changed
... usedReference 0..*Reference(US Core Implantable Device Profile)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

Differential View

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*USCoreProcedureProfileCDMH Procedure
... code S1..1CodeableConceptIdentification of the procedure
.... cdmh-pcornet-px-source S0..1codePCORNet Procedure Information Source
URL: http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-pcornet-px-source
Binding: PCORNet Information Source HC Subtype (extensible): Procedure Information Source subtypes within a healthcare organization.

... subject S1..1Reference(CDMH Patient)Who the procedure was performed on
... encounter S0..1Reference(CDMH Encounter)Encounter created as part of
.... actor S1..1Reference(US Core Practitioner Profile)The reference to the practitioner
... focalDevice S0..*BackboneElementManipulated, implanted, or removed device
.... manipulated S1..1Reference(US Core Implantable Device Profile)Device that was changed
... usedReference S0..*Reference(US Core Implantable Device Profile)Items used during procedure
... usedCode S0..*CodeableConceptCoded items used during the procedure

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*USCoreProcedureProfileCDMH Procedure
... id Σ0..1stringLogical 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)
Max Binding: AllLanguages: A human language.

... 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(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..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

.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... cdmh-pcornet-px-source S0..1codePCORNet Procedure Information Source
URL: http://hl7.org/fhir/us/cdmh/StructureDefinition/cdmh-pcornet-px-source
Binding: PCORNet Information Source HC Subtype (extensible): Procedure Information Source subtypes within a healthcare organization.


.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(CDMH Patient)Who the procedure was performed on
... encounter SΣ0..1Reference(CDMH Encounter)Encounter created as part of
... performed[x] SΣ1..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 SΣ0..*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 SΣ1..1Reference(US Core Practitioner Profile)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..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was 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 S0..*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 S1..1Reference(US Core Implantable Device Profile)Device that was changed
... usedReference S0..*Reference(US Core Implantable Device Profile)Items used during procedure
... usedCode S0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Max Binding: AllLanguages
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codeextensibleUSCoreProcedureCodes
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdPathDetailsRequirements
dom-2ProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ProcedureIf 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-4ProcedureIf 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-5ProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1Procedure.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.partOfAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.statusReasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.code.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.code.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.code.extension:pcornet-px-sourceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.code.extension:pcornet-px-sourceMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.code.codingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.code.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performed[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.recorderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.asserterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performer.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.performer.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.performer.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.performer.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.performer.functionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performer.actorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performer.onBehalfOfAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.locationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.reasonCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.reasonReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.outcomeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.reportAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.complicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.complicationDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.followUpAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDeviceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDevice.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.focalDevice.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.focalDevice.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.focalDevice.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.focalDevice.actionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDevice.manipulatedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.usedReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.usedCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())