Imaging Diagnostic Report
0.0.1-current - ci-build
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
Official URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idr-procedure | Version: 0.0.1-current | |||
Draft as of 2024-06-25 | Computable Name: IDRProcedure |
A procedure that was performed on the patient.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | Procedure | An action that is being or was performed on 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 |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard | |
Procedure.complication | example | ConditionProblemDiagnosisCodeshttp://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
| |||||
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 |
Path | Conformance | ValueSet | URI |
Procedure.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard | |
Procedure.statusReason | example | ProcedureNotPerformedReasonSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | |
Procedure.category | example | ProcedureCategoryCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | |
Procedure.code | example | ProcedureCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | |
Procedure.reason | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | |
Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | |
Procedure.outcome | example | ProcedureOutcomeCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | |
Procedure.complication | example | ConditionProblemDiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | |
Procedure.followUp | example | ProcedureFollowUpCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | |
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | |
Procedure.used | example | DeviceTypehttp://hl7.org/fhir/ValueSet/device-type from the FHIR Standard |
This structure is derived from Procedure
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 |
Path | Conformance | ValueSet | URI |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard | |
Procedure.complication | example | ConditionProblemDiagnosisCodeshttp://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
| |||||
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 |
Path | Conformance | ValueSet | URI |
Procedure.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|5.0.0 from the FHIR Standard | |
Procedure.statusReason | example | ProcedureNotPerformedReasonSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard | |
Procedure.category | example | ProcedureCategoryCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard | |
Procedure.code | example | ProcedureCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-code from the FHIR Standard | |
Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard | |
Procedure.reason | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard | |
Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site from the FHIR Standard | |
Procedure.outcome | example | ProcedureOutcomeCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard | |
Procedure.complication | example | ConditionProblemDiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard | |
Procedure.followUp | example | ProcedureFollowUpCodesSNOMEDCThttp://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard | |
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action from the FHIR Standard | |
Procedure.used | example | DeviceTypehttp://hl7.org/fhir/ValueSet/device-type from the FHIR Standard |
This structure is derived from Procedure
Other representations of profile: CSV, Excel, Schematron