ICHOM Patient Centered Outcomes Measure Set for Breast Cancer, published by HL7 International - Clinical Interoperability Council 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/fhir-ichom-breast-cancer-ig/ and changes regularly. See the Directory of published versions
Page standards status: Informative |
Definitions for the reoperation-surgery resource profile.
Guidance on how to interpret the contents of this table can be found here.
1. Procedure | |
2. Procedure.partOf | |
Definition | A larger event of which this particular procedure is a component or step. In this case, the original procedure that prompted the reoperation. A larger event of which this particular procedure is a component or step. |
Must Support | true |
3. Procedure.status | |
Must Support | true |
4. Procedure.category | |
Must Support | true |
Pattern Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="http://snomed.info/sct"/> <code value="261554009"/> <display value="Reoperation"/> </coding> </valueCodeableConcept> |
5. Procedure.code | |
Binding | The codes SHALL be taken from Type of re-operationFor example codes, see ProcedureCodes(SNOMEDCT) |
Must Support | true |
6. Procedure.subject | |
Type | Reference(BreastCancerPatient|Patient|Group) |
Must Support | true |
7. Procedure.performed[x] | |
Type | Choice of: , string, Period, Range, Age |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
8. Procedure.reasonCode | |
Binding | The codes SHOULD be taken from Reasoncode of the re-operationFor example codes, see ProcedureReasonCodes |
Must Support | true |
9. Procedure.reasonReference | |
Type | Reference(PrimaryBreastCancerCondition|Condition|Observation|Procedure|DiagnosticReport|DocumentReference) |
Must Support | true |
Guidance on how to interpret the contents of this table can be found here.
1. Procedure | |
Definition | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. |
Control | 0..* |
Summary | false |
Invariants | Defined on this element dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty()) dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (: text.`div`.exists()) |
2. Procedure.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Summary | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
3. Procedure.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Summary | false |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
4. Procedure.partOf | |
Definition | A larger event of which this particular procedure is a component or step. In this case, the original procedure that prompted the reoperation. A larger event of which this particular procedure is a component or step. |
Control | 0..* |
Type | Reference(Procedure|Observation|MedicationAdministration) |
Must Support | true |
Must Support Types | No must-support rules about the choice of types/profiles |
Summary | true |
Alternate Names | container |
Comments | The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
5. Procedure.status | |
Definition | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. |
Control | 1..1 |
Binding | The codes SHALL be taken from EventStatus A code specifying the state of the procedure. |
Type | code |
Is Modifier | true |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Comments | The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
6. Procedure.category | |
Definition | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). |
Control | 0..1 |
Binding | For example codes, see ProcedureCategoryCodes(SNOMEDCT) A code that classifies a procedure for searching, sorting and display purposes. |
Type | CodeableConcept |
Must Support | true |
Summary | true |
Pattern Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="http://snomed.info/sct"/> <code value="261554009"/> <display value="Reoperation"/> </coding> </valueCodeableConcept> |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
7. Procedure.code | |
Definition | The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). |
Control | 0..1 |
Binding | The codes SHALL be taken from Type of re-operationFor example codes, see ProcedureCodes(SNOMEDCT) |
Type | CodeableConcept |
Must Support | true |
Summary | true |
Requirements | 0..1 to account for primarily narrative only resources. |
Alternate Names | type |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
8. Procedure.subject | |
Definition | The person, animal or group on which the procedure was performed. |
Control | 1..1 |
Type | Reference(BreastCancerPatient|Patient|Group) |
Must Support | true |
Summary | true |
Alternate Names | patient |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
9. Procedure.performed[x] | |
Definition | Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. |
Control | 0..1 |
Type | Choice of: dateTime, string, Period, Range, Age |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Must Support | true |
Summary | true |
Comments | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
10. Procedure.reasonCode | |
Definition | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. |
Control | 0..* |
Binding | The codes SHOULD be taken from Reasoncode of the re-operationFor example codes, see ProcedureReasonCodes |
Type | CodeableConcept |
Must Support | true |
Summary | true |
Comments | Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
11. Procedure.reasonReference | |
Definition | The justification of why the procedure was performed. |
Control | 0..* |
Type | Reference(PrimaryBreastCancerCondition|Condition|Observation|Procedure|DiagnosticReport|DocumentReference) |
Must Support | true |
Summary | true |
Comments | It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here.
1. Procedure | |||||
Definition | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. | ||||
Control | 0..* | ||||
Summary | false | ||||
2. Procedure.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Control | 0..1 | ||||
Type | id | ||||
Summary | true | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
3. Procedure.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Summary | true | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
4. Procedure.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
5. Procedure.language | |||||
Definition | The base language in which the resource is written. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages
A human language
| ||||
Type | code | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
6. Procedure.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
7. Procedure.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
8. Procedure.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
9. Procedure.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
10. Procedure.identifier | |||||
Definition | Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Summary | true | ||||
Requirements | Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. | ||||
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
11. Procedure.instantiatesCanonical | |||||
Definition | The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. | ||||
Control | 0..* | ||||
Type | canonical(PlanDefinition|ActivityDefinition|Measure|OperationDefinition|Questionnaire) | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
12. Procedure.instantiatesUri | |||||
Definition | The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. | ||||
Control | 0..* | ||||
Type | uri | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
13. Procedure.basedOn | |||||
Definition | A reference to a resource that contains details of the request for this procedure. | ||||
Control | 0..* | ||||
Type | Reference(CarePlan|ServiceRequest) | ||||
Summary | true | ||||
Alternate Names | fulfills | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
14. Procedure.partOf | |||||
Definition | A larger event of which this particular procedure is a component or step. In this case, the original procedure that prompted the reoperation. | ||||
Control | 0..* | ||||
Type | Reference(Procedure|Observation|MedicationAdministration) | ||||
Must Support | true | ||||
Must Support Types | No must-support rules about the choice of types/profiles | ||||
Summary | true | ||||
Alternate Names | container | ||||
Comments | The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
15. Procedure.status | |||||
Definition | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from EventStatus A code specifying the state of the procedure | ||||
Type | code | ||||
Is Modifier | true | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Comments | The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
16. Procedure.statusReason | |||||
Definition | Captures the reason for the current state of the procedure. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedureNotPerformedReason(SNOMED-CT) A code that identifies the reason a procedure was not performed | ||||
Type | CodeableConcept | ||||
Summary | true | ||||
Alternate Names | Suspended Reason, Cancelled Reason | ||||
Comments | This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
17. Procedure.category | |||||
Definition | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedureCategoryCodes(SNOMEDCT) A code that classifies a procedure for searching, sorting and display purposes | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Summary | true | ||||
Pattern Value | <valueCodeableConcept xmlns="http://hl7.org/fhir"> <coding> <system value="http://snomed.info/sct"/> <code value="261554009"/> <display value="Reoperation"/> </coding> </valueCodeableConcept> | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
18. Procedure.code | |||||
Definition | The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from Type of re-operation | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | 0..1 to account for primarily narrative only resources. | ||||
Alternate Names | type | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
19. Procedure.subject | |||||
Definition | The person, animal or group on which the procedure was performed. | ||||
Control | 1..1 | ||||
Type | Reference(BreastCancerPatient) | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | patient | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
20. Procedure.encounter | |||||
Definition | The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. | ||||
Control | 0..1 | ||||
Type | Reference(Encounter) | ||||
Summary | true | ||||
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
21. Procedure.performed[x] | |||||
Definition | Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Comments | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
22. Procedure.recorder | |||||
Definition | Individual who recorded the record and takes responsibility for its content. | ||||
Control | 0..1 | ||||
Type | Reference(Patient|RelatedPerson|Practitioner|PractitionerRole) | ||||
Summary | true | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
23. Procedure.asserter | |||||
Definition | Individual who is making the procedure statement. | ||||
Control | 0..1 | ||||
Type | Reference(Patient|RelatedPerson|Practitioner|PractitionerRole) | ||||
Summary | true | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
24. Procedure.performer | |||||
Definition | Limited to "real" people rather than equipment. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Summary | true | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
25. Procedure.performer.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Control | 0..1 | ||||
Type | string | ||||
XML Representation | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
26. Procedure.performer.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
27. Procedure.performer.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
28. Procedure.performer.function | |||||
Definition | Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedurePerformerRoleCodes A code that identifies the role of a performer of the procedure | ||||
Type | CodeableConcept | ||||
Summary | true | ||||
Requirements | Allows disambiguation of the types of involvement of different performers. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
29. Procedure.performer.actor | |||||
Definition | The practitioner who was involved in the procedure. | ||||
Control | 1..1 | ||||
Type | Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson|Device) | ||||
Summary | true | ||||
Requirements | A reference to Device supports use cases, such as pacemakers. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
30. Procedure.performer.onBehalfOf | |||||
Definition | The organization the device or practitioner was acting on behalf of. | ||||
Control | 0..1 | ||||
Type | Reference(Organization) | ||||
Summary | false | ||||
Requirements | Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
31. Procedure.location | |||||
Definition | The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. | ||||
Control | 0..1 | ||||
Type | Reference(Location) | ||||
Summary | true | ||||
Requirements | Ties a procedure to where the records are likely kept. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
32. Procedure.reasonCode | |||||
Definition | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. | ||||
Control | 0..* | ||||
Binding | The codes SHOULD be taken from Reasoncode of the re-operation | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Summary | true | ||||
Comments | Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
33. Procedure.reasonReference | |||||
Definition | The justification of why the procedure was performed. | ||||
Control | 0..* | ||||
Type | Reference(PrimaryBreastCancerCondition) | ||||
Must Support | true | ||||
Summary | true | ||||
Comments | It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
34. Procedure.bodySite | |||||
Definition | Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. | ||||
Control | 0..* | ||||
Binding | For example codes, see SNOMEDCTBodyStructures Codes describing anatomical locations. May include laterality | ||||
Type | CodeableConcept | ||||
Summary | true | ||||
Comments | If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
35. Procedure.outcome | |||||
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed? | ||||
Control | 0..1 | ||||
Binding | For example codes, see ProcedureOutcomeCodes(SNOMEDCT) An outcome of a procedure - whether it was resolved or otherwise | ||||
Type | CodeableConcept | ||||
Summary | true | ||||
Comments | If outcome contains narrative text only, it can be captured using the CodeableConcept.text. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
36. Procedure.report | |||||
Definition | This could be a histology result, pathology report, surgical report, etc. | ||||
Control | 0..* | ||||
Type | Reference(DiagnosticReport|DocumentReference|Composition) | ||||
Summary | false | ||||
Comments | There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
37. Procedure.complication | |||||
Definition | Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. | ||||
Control | 0..* | ||||
Binding | For example codes, see Condition/Problem/DiagnosisCodes Codes describing complications that resulted from a procedure | ||||
Type | CodeableConcept | ||||
Summary | false | ||||
Comments | If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
38. Procedure.complicationDetail | |||||
Definition | Any complications that occurred during the procedure, or in the immediate post-performance period. | ||||
Control | 0..* | ||||
Type | Reference(Condition) | ||||
Summary | false | ||||
Requirements | This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
39. Procedure.followUp | |||||
Definition | If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. | ||||
Control | 0..* | ||||
Binding | For example codes, see ProcedureFollowUpCodes(SNOMEDCT) Specific follow up required for a procedure e.g. removal of sutures | ||||
Type | CodeableConcept | ||||
Summary | false | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
40. Procedure.note | |||||
Definition | Any other notes and comments about the procedure. | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Summary | false | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
41. Procedure.focalDevice | |||||
Definition | A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Summary | false | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
42. Procedure.focalDevice.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Control | 0..1 | ||||
Type | string | ||||
XML Representation | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
43. Procedure.focalDevice.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
44. Procedure.focalDevice.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
45. Procedure.focalDevice.action | |||||
Definition | The kind of change that happened to the device during the procedure. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodes A kind of change that happened to the device during the procedure | ||||
Type | CodeableConcept | ||||
Summary | false | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
46. Procedure.focalDevice.manipulated | |||||
Definition | The device that was manipulated (changed) during the procedure. | ||||
Control | 1..1 | ||||
Type | Reference(Device) | ||||
Summary | false | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
47. Procedure.usedReference | |||||
Definition | Identifies medications, devices and any other substance used as part of the procedure. | ||||
Control | 0..* | ||||
Type | Reference(Device|Medication|Substance) | ||||
Summary | false | ||||
Requirements | Used for tracking contamination, etc. | ||||
Comments | For devices actually implanted or removed, use Procedure.device. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
48. Procedure.usedCode | |||||
Definition | Identifies coded items that were used as part of the procedure. | ||||
Control | 0..* | ||||
Binding | For example codes, see FHIRDeviceTypes Codes describing items used during a procedure | ||||
Type | CodeableConcept | ||||
Summary | false | ||||
Comments | For devices actually implanted or removed, use Procedure.device. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |