Imaging Diagnostic Report, published by IHE Radiology Technical Committee. This guide is not an authorized publication; it is the continuous build for version 0.0.1-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/RAD.IDR/ and changes regularly. See the Directory of published versions

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Resource Profile: Procedure and material information in Imaging Diagnostic Report

A procedure that was performed on the patient.

Usage:

• Refer to this Resource Profile: IDR Imaging Procedure

Formal Views of Profile Content

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

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

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on an individual or entity
text	S	0..1	Narrative	Text summary of the resource, for human interpretation
complication	S	0..*	CodeableReference(Condition)	Complication following the procedure
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on an individual or entity
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
text	S	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
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.
subject	Σ	1..1	Reference(Patient | Group | Device | Practitioner | Organization | Location)	Individual or entity the procedure was performed on
complication	S	0..*	CodeableReference(Condition)	Complication following the procedure Binding: ConditionProblemDiagnosisCodes (example): Codes describing complications that resulted from a procedure.
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard
Procedure.complication	example	ConditionProblemDiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on an individual or entity
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: AllLanguages (required): IETF language tag for a human language Additional Bindings Purpose CommonLanguages Starter Set
text	S	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	?!Σ	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: ProcedureNotPerformedReasonSNOMEDCT (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..*	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodesSNOMEDCT (example): A code that classifies a procedure for searching, sorting and display purposes.
code	Σ	0..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodesSNOMEDCT (example): A code to identify a specific procedure .
subject	Σ	1..1	Reference(Patient | Group | Device | Practitioner | Organization | Location)	Individual or entity the procedure was performed on
focus	Σ	0..1	Reference(Patient | Group | RelatedPerson | Practitioner | Organization | CareTeam | PractitionerRole | Specimen)	Who is the target of the procedure when it is not the subject of record only
encounter	Σ	0..1	Reference(Encounter)	The Encounter during which this Procedure was created
occurrence[x]	Σ	0..1		When the procedure occurred or is occurring
occurrenceDateTime			dateTime
occurrencePeriod			Period
occurrenceString			string
occurrenceAge			Age
occurrenceRange			Range
occurrenceTiming			Timing
recorded	Σ	0..1	dateTime	When the procedure was first captured in the subject's record
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
reported[x]	Σ	0..1		Reported rather than primary record
reportedBoolean			boolean
reportedReference			Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
performer	ΣC	0..*	BackboneElement	Who performed the procedure and what they did prc-1: Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole
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	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | CareTeam | HealthcareService)	Who performed the procedure
onBehalfOf	C	0..1	Reference(Organization)	Organization the device or practitioner was acting for
period		0..1	Period	When the performer performed the procedure
location	Σ	0..1	Reference(Location)	Where the procedure happened
reason	Σ	0..*	CodeableReference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodesSNOMEDCT (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	S	0..*	CodeableReference(Condition)	Complication following the procedure Binding: ConditionProblemDiagnosisCodes (example): Codes describing complications that resulted from a procedure.
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodesSNOMEDCT (example): Specific follow up required for a procedure e.g. removal of sutures.
note	S	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
used		0..*	CodeableReference(Device | Medication | Substance | BiologicallyDerivedProduct)	Items used during procedure Binding: DeviceType (example): Codes describing items used during a procedure.
supportingInfo		0..*	Reference(Resource)	Extra information relevant to the procedure
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReasonSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodesSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	example	ProcedureCodesSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reason	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodesSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	ConditionProblemDiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodesSNOMEDCT 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.used	example	DeviceType http://hl7.org/fhir/ValueSet/device-type from the FHIR Standard

This structure is derived from Procedure

Summary

Must-Support: 3 elements

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on an individual or entity
text	S	0..1	Narrative	Text summary of the resource, for human interpretation
complication	S	0..*	CodeableReference(Condition)	Complication following the procedure
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on an individual or entity
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
text	S	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
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.
subject	Σ	1..1	Reference(Patient | Group | Device | Practitioner | Organization | Location)	Individual or entity the procedure was performed on
complication	S	0..*	CodeableReference(Condition)	Complication following the procedure Binding: ConditionProblemDiagnosisCodes (example): Codes describing complications that resulted from a procedure.
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard
Procedure.complication	example	ConditionProblemDiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on an individual or entity
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: AllLanguages (required): IETF language tag for a human language Additional Bindings Purpose CommonLanguages Starter Set
text	S	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	?!Σ	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: ProcedureNotPerformedReasonSNOMEDCT (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..*	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodesSNOMEDCT (example): A code that classifies a procedure for searching, sorting and display purposes.
code	Σ	0..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodesSNOMEDCT (example): A code to identify a specific procedure .
subject	Σ	1..1	Reference(Patient | Group | Device | Practitioner | Organization | Location)	Individual or entity the procedure was performed on
focus	Σ	0..1	Reference(Patient | Group | RelatedPerson | Practitioner | Organization | CareTeam | PractitionerRole | Specimen)	Who is the target of the procedure when it is not the subject of record only
encounter	Σ	0..1	Reference(Encounter)	The Encounter during which this Procedure was created
occurrence[x]	Σ	0..1		When the procedure occurred or is occurring
occurrenceDateTime			dateTime
occurrencePeriod			Period
occurrenceString			string
occurrenceAge			Age
occurrenceRange			Range
occurrenceTiming			Timing
recorded	Σ	0..1	dateTime	When the procedure was first captured in the subject's record
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
reported[x]	Σ	0..1		Reported rather than primary record
reportedBoolean			boolean
reportedReference			Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
performer	ΣC	0..*	BackboneElement	Who performed the procedure and what they did prc-1: Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole
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	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | CareTeam | HealthcareService)	Who performed the procedure
onBehalfOf	C	0..1	Reference(Organization)	Organization the device or practitioner was acting for
period		0..1	Period	When the performer performed the procedure
location	Σ	0..1	Reference(Location)	Where the procedure happened
reason	Σ	0..*	CodeableReference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodesSNOMEDCT (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	S	0..*	CodeableReference(Condition)	Complication following the procedure Binding: ConditionProblemDiagnosisCodes (example): Codes describing complications that resulted from a procedure.
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodesSNOMEDCT (example): Specific follow up required for a procedure e.g. removal of sutures.
note	S	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
used		0..*	CodeableReference(Device | Medication | Substance | BiologicallyDerivedProduct)	Items used during procedure Binding: DeviceType (example): Codes describing items used during a procedure.
supportingInfo		0..*	Reference(Resource)	Extra information relevant to the procedure
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReasonSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodesSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	example	ProcedureCodesSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reason	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodesSNOMEDCT http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	ConditionProblemDiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodesSNOMEDCT 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.used	example	DeviceType http://hl7.org/fhir/ValueSet/device-type from the FHIR Standard

This structure is derived from Procedure

Summary

Must-Support: 3 elements

Other representations of profile: CSV, Excel, Schematron