Clinical Practice Guidelines
2.0.0 - trial-use
Clinical Practice Guidelines
2.0.0 - trial-use
Clinical Practice Guidelines, published by HL7 International / Clinical Decision Support. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cqf-recommendations/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-procedure | Version: 2.0.0 | |||
| Active as of 2024-11-21 | Computable Name: CPGProcedure | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.48.42.99 | ||||
Documents a procedure as an activity within the context of a computable clinical practice guideline
This is an activity event profile
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   instantiatesCaseFeature |
S | 0..1 | canonical(CPG Case Feature Definition) | CPG Instantiates Case Feature Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature |
| caseFeatureType |
S | 0..1 | code | CPG Case Feature Type Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType Binding: CPG Case Feature Type Value Set (required): Whether the case feature is asserted or inferred |
 caseFeaturePertinence |
S | 0..1 | code | CPG Case Feature Pertinence Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence Binding: CPG Case Feature Pertinence Value Set (required): Describes the pertinence of a case feature |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
 identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical |
SΣ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Source |
 basedOn |
SΣ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
| statusReason |
SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| category |
SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| code |
SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject |
SΣ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of |
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
 reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | Pertinent information |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | |
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | |
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | |
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| instantiatesCaseFeature |
S | 0..1 | canonical(CPG Case Feature Definition) | CPG Instantiates Case Feature Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature | ||||
| caseFeatureType |
S | 0..1 | code | CPG Case Feature Type Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType Binding: CPG Case Feature Type Value Set (required): Whether the case feature is asserted or inferred | ||||
| caseFeaturePertinence |
S | 0..1 | code | CPG Case Feature Pertinence Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence Binding: CPG Case Feature Pertinence Value Set (required): Describes the pertinence of a case feature | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
SΣ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Source | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
SΣ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
| statusReason |
SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code |
SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject |
SΣ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
 performed[x] |
Σ | 0..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| recorder |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer |
Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location |
Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | Pertinent information | ||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome |
Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report |
0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail |
0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note |
0..* | Annotation | Additional information about the procedure | |||||
| focalDevice |
0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
1..1 | Reference(Device) | Device that was changed | |||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Procedure
Differential View
This structure is derived from Procedure
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| instantiatesCaseFeature |
S | 0..1 | canonical(CPG Case Feature Definition) | CPG Instantiates Case Feature Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature |
| caseFeatureType |
S | 0..1 | code | CPG Case Feature Type Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType Binding: CPG Case Feature Type Value Set (required): Whether the case feature is asserted or inferred |
| caseFeaturePertinence |
S | 0..1 | code | CPG Case Feature Pertinence Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence Binding: CPG Case Feature Pertinence Value Set (required): Describes the pertinence of a case feature |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical |
SΣ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Source |
| basedOn |
SΣ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
| statusReason |
SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| category |
SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| code |
SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject |
SΣ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of |
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | Pertinent information |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | |
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | |
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | |
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| instantiatesCaseFeature |
S | 0..1 | canonical(CPG Case Feature Definition) | CPG Instantiates Case Feature Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature | ||||
| caseFeatureType |
S | 0..1 | code | CPG Case Feature Type Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType Binding: CPG Case Feature Type Value Set (required): Whether the case feature is asserted or inferred | ||||
| caseFeaturePertinence |
S | 0..1 | code | CPG Case Feature Pertinence Extension URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence Binding: CPG Case Feature Pertinence Value Set (required): Describes the pertinence of a case feature | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
SΣ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Source | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
SΣ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
| statusReason |
SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code |
SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject |
SΣ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] |
Σ | 0..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| recorder |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer |
Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location |
Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | Pertinent information | ||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome |
Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report |
0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail |
0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note |
0..* | Annotation | Additional information about the procedure | |||||
| focalDevice |
0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
1..1 | Reference(Device) | Device that was changed | |||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Procedure
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 International / Clinical Decision Support. Package hl7.fhir.uv.cpg#2.0.0 based on FHIR 4.0.1. Generated 2024-11-21
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change
