De-Identification, Anonymization, Redaction Toolkit Services
0.1.0 - STU1 Release 1 - Standard for Trial-Use United States of America flag

De-Identification, Anonymization, Redaction Toolkit Services, published by HL7 International / Cross Group Projects. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-darts/ and changes regularly. See the Directory of published versions

Resource Profile: De-Identified UDS Plus Procedure

Official URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-procedure Version: 0.1.0
Standards status: Trial-use Maturity Level: 1 Computable Name: UDSPlusProcedure

The UDS+ profile is based on the Procedure resource and establishes the core elements, extensions, vocabularies and value sets for representing procedures for UDS+ program.

All canonical (Official) URLs will be changed in the future and are not available currently on the web.

Introduction

This profile is used to represent de-identified Procedure information. The de-identification process has to remove all data elements not explicitly identified as "SUPPORTED" in the profile.

The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.

According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes Procedure.occurenceDateTime.

In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a Procedure resource text element may contain information such as the Procedure date, patient information. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.

Ids and References

The original Procedure resource id should not be included in the De-identified Procedure instance. Instead a new id should be created and provided as part of the FHIR resource. The Data Submitter should be capable of using the generated id to relink the data to the original Procedure. All resource references to the Procedure submitted as part of the UDS+ report should refer to newly generated id.

Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed

  • subject
  • encounter

Date Truncation

The Data Submitter has to truncate the following dates to only have a precision of year

  • performedDateTime
  • extension.recordedDate

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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.
... code SΣ 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] SΣ 0..1 When the procedure was performed
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... performer SΣ 0..* BackboneElement The people who performed the procedure
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦8.0.1 US Core v8.0
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id S 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... text 0..0 Cannot include any text in the resource as part of the de-identified data.
... contained 0..0 Cannot include any contained resources in the resource as part of the de-identified data.
.... extension:recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... status S 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... statusReason S 0..1 CodeableConcept Reason for current status
... code S 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures
... subject S 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter S 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] S 0..1 dateTime, Period, string, Age, Range When the procedure was performed
... performer S 0..* BackboneElement The people who performed the procedure
... bodySite S 0..* CodeableConcept Target body sites

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.code Base extensible US Core Procedure Codes 📦8.0.1 US Core v8.0
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
... partOf Σ 0..* Reference(Procedure | 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 Σ 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 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] SΣ 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 SΣ 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 Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite SΣ 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦8.0.1 US Core v8.0
Procedure.performer.​function Base example Procedure Performer Role Codes 📍4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📍4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... extension:recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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.
... code SΣ 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] SΣ 0..1 When the procedure was performed
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
... performer SΣ 0..* BackboneElement The people who performed the procedure
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦8.0.1 US Core v8.0
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Procedure If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Procedure If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Procedure If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Procedure If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Procedure A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id S 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... text 0..0 Cannot include any text in the resource as part of the de-identified data.
... contained 0..0 Cannot include any contained resources in the resource as part of the de-identified data.
.... extension:recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... status S 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... statusReason S 0..1 CodeableConcept Reason for current status
... code S 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures
... subject S 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter S 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] S 0..1 dateTime, Period, string, Age, Range When the procedure was performed
... performer S 0..* BackboneElement The people who performed the procedure
... bodySite S 0..* CodeableConcept Target body sites

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.code Base extensible US Core Procedure Codes 📦8.0.1 US Core v8.0

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://hl7.org/fhir/us/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
... partOf Σ 0..* Reference(Procedure | 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 Σ 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 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures
... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] SΣ 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 SΣ 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 Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite SΣ 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦8.0.1 US Core v8.0
Procedure.performer.​function Base example Procedure Performer Role Codes 📍4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📍4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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