International Patient Summary Implementation Guide, published by HL7 International / Patient Care. 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/fhir-ips/ and changes regularly. See the Directory of published versions

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• Detailed Descriptions
• Mappings
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Resource Profile: Procedure (IPS)

This profile represents the constraints applied to the Procedure resource by the IPS project, which specifies an entry of the History of Procedure for the international patient summary based on the FHIR standard R4.

Usage:

• Use this Resource Profile: Bundle (IPS)
• Refer to this Resource Profile: Composition (IPS)

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	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. ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConceptIPS	Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient (IPS))	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
performed[x]	SΣ	1..1		When the procedure was performed ele-1: All FHIR elements must have a @value or children
performed[x]All Types				Content/Rules for all Types
Slices for extension				Content/Rules for all slices
data-absent-reason	S	0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure ele-1: All FHIR elements must have a @value or children
performer	Σ	0..*	BackboneElement	The people who performed the procedure ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
actor	Σ	1..1	Reference(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS))	The reference to the practitioner ele-1: All FHIR elements must have a @value or children
onBehalfOf		0..1	Reference(Organization (IPS))	Organization the device or practitioner was acting for ele-1: All FHIR elements must have a @value or children
bodySite	Σ	0..*	CodeableConceptIPS	Target body sites Binding: SNOMEDCTBodyStructures (preferred) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	preferred	ProceduresUvIps http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips from this IG
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

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

Name	Flags	Card.	Type	Description & Constraints
Procedure			Procedure
code	S	1..1	CodeableConceptIPS	Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
subject	S	1..1	Reference(Patient (IPS))	Who the procedure was performed on
reference	S	1..1	string	Literal reference, Relative, internal or absolute URL
performed[x]	S	1..1	dateTime, Period, string, Age, Range	When the procedure was performed
Slices for extension				Content/Rules for all slices
data-absent-reason	S	0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
asserter		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer		0..*	BackboneElement	The people who performed the procedure
actor		1..1	Reference(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS))	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization (IPS))	Organization the device or practitioner was acting for
bodySite		0..*	CodeableConceptIPS	Target body sites Binding: SNOMEDCTBodyStructures (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	preferred	ProceduresUvIps http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips from this IG
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
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	?!Σ	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	Σ	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	CodeableConceptIPS	Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
subject	SΣ	1..1	Reference(Patient (IPS))	Who the procedure was performed on
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performed[x]All Types				Content/Rules for all Types
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
data-absent-reason	S	0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
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(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS))	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization (IPS))	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	Σ	0..*	CodeableConceptIPS	Target body sites Binding: SNOMEDCTBodyStructures (preferred)
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	preferred	ProceduresUvIps http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips from this IG
Procedure.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

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

Summary

Mandatory: 3 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• Codeable Concept (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips)
• Patient (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Patient-uv-ips)
• Device - Performer or Observer (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Device-observer-uv-ips)
• Practitioner (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Practitioner-uv-ips)
• PractitionerRole (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/PractitionerRole-uv-ips)
• Organization (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Organization-uv-ips)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/data-absent-reason

Maturity: 2

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	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. ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConceptIPS	Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient (IPS))	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
performed[x]	SΣ	1..1		When the procedure was performed ele-1: All FHIR elements must have a @value or children
performed[x]All Types				Content/Rules for all Types
Slices for extension				Content/Rules for all slices
data-absent-reason	S	0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure ele-1: All FHIR elements must have a @value or children
performer	Σ	0..*	BackboneElement	The people who performed the procedure ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
actor	Σ	1..1	Reference(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS))	The reference to the practitioner ele-1: All FHIR elements must have a @value or children
onBehalfOf		0..1	Reference(Organization (IPS))	Organization the device or practitioner was acting for ele-1: All FHIR elements must have a @value or children
bodySite	Σ	0..*	CodeableConceptIPS	Target body sites Binding: SNOMEDCTBodyStructures (preferred) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	preferred	ProceduresUvIps http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips from this IG
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

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()

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure			Procedure
code	S	1..1	CodeableConceptIPS	Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
subject	S	1..1	Reference(Patient (IPS))	Who the procedure was performed on
reference	S	1..1	string	Literal reference, Relative, internal or absolute URL
performed[x]	S	1..1	dateTime, Period, string, Age, Range	When the procedure was performed
Slices for extension				Content/Rules for all slices
data-absent-reason	S	0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
asserter		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer		0..*	BackboneElement	The people who performed the procedure
actor		1..1	Reference(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS))	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization (IPS))	Organization the device or practitioner was acting for
bodySite		0..*	CodeableConceptIPS	Target body sites Binding: SNOMEDCTBodyStructures (preferred)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	preferred	ProceduresUvIps http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips from this IG
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
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	?!Σ	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	Σ	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	CodeableConceptIPS	Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
subject	SΣ	1..1	Reference(Patient (IPS))	Who the procedure was performed on
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performed[x]All Types				Content/Rules for all Types
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
data-absent-reason	S	0..1	code	performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
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(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS))	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization (IPS))	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	Σ	0..*	CodeableConceptIPS	Target body sites Binding: SNOMEDCTBodyStructures (preferred)
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	preferred	ProceduresUvIps http://hl7.org/fhir/uv/ips/ValueSet/procedures-uv-ips from this IG
Procedure.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

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

Summary

Mandatory: 3 elements
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• Codeable Concept (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips)
• Patient (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Patient-uv-ips)
• Device - Performer or Observer (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Device-observer-uv-ips)
• Practitioner (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Practitioner-uv-ips)
• PractitionerRole (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/PractitionerRole-uv-ips)
• Organization (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Organization-uv-ips)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/data-absent-reason

Maturity: 2

Other representations of profile: CSV, Excel, Schematron