Imaging Diagnostic Report
0.0.1-current - ci-build International flag

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

Resource Profile: IDR Patient History Procedure

Official URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idr-patient-history-procedure Version: 0.0.1-current
Draft as of 2026-01-24 Computable Name: IDRPatientHistoryProcedure

A patient history entry describing a past procedure performed on them.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* Procedure An action that is being or was performed on an individual or entity
Constraints: con-4
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required EventStatus 📍6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-4 error Procedure bodyStructure SHALL only be present if Procedure.bodySite is not present bodySite.exists() implies bodyStructure.empty()
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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').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())

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* Procedure An action that is being or was performed on an individual or entity
Constraints: con-4
... 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 BindingsPurpose
CommonLanguages Starter
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | MedicationRequest) 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
Constraints: prc-1
.... 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: ParticipantRoles (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 ΣC 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
... bodyStructure 0..* Reference(BodyStructure) Target body structure
... outcome Σ 0..* CodeableReference(Observation) 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 Σ 0..* CodeableReference(Condition) Complication following the procedure
Binding: ConditionProblemDiagnosisCodes (example): Codes describing complications that resulted from a procedure.
... followUp 0..* CodeableReference(ServiceRequest | PlanDefinition) Instructions for follow up
Binding: ProcedureFollowUpCodesSNOMEDCT (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
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base required All Languages 📍6.0.0-ballot3 FHIR Std.
Procedure.status Base required EventStatus 📍6.0.0-ballot3 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.code Base example Procedure Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.performer.​function Base example Participant Roles 📍6.0.0-ballot3 FHIR Std.
Procedure.reason Base example Procedure Reason Codes 📍6.0.0-ballot3 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📍6.0.0-ballot3 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍6.0.0-ballot3 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍6.0.0-ballot3 FHIR Std.
Procedure.used Base example Device Type 📍6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-4 error Procedure bodyStructure SHALL only be present if Procedure.bodySite is not present bodySite.exists() implies bodyStructure.empty()
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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').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())
prc-1 error Procedure.performer Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole onBehalfOf.exists() and actor.resolve().exists() implies actor.resolve().where($this is Practitioner or $this is PractitionerRole).empty()

This structure is derived from Procedure

Summary

Must-Support: 1 element

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* Procedure An action that is being or was performed on an individual or entity
Constraints: con-4
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required EventStatus 📍6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-4 error Procedure bodyStructure SHALL only be present if Procedure.bodySite is not present bodySite.exists() implies bodyStructure.empty()
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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').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())

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure C 0..* Procedure An action that is being or was performed on an individual or entity
Constraints: con-4
... 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 BindingsPurpose
CommonLanguages Starter
... text S 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest | MedicationRequest) 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
Constraints: prc-1
.... 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: ParticipantRoles (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 ΣC 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
... bodyStructure 0..* Reference(BodyStructure) Target body structure
... outcome Σ 0..* CodeableReference(Observation) 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 Σ 0..* CodeableReference(Condition) Complication following the procedure
Binding: ConditionProblemDiagnosisCodes (example): Codes describing complications that resulted from a procedure.
... followUp 0..* CodeableReference(ServiceRequest | PlanDefinition) Instructions for follow up
Binding: ProcedureFollowUpCodesSNOMEDCT (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
... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base required All Languages 📍6.0.0-ballot3 FHIR Std.
Procedure.status Base required EventStatus 📍6.0.0-ballot3 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.code Base example Procedure Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.performer.​function Base example Participant Roles 📍6.0.0-ballot3 FHIR Std.
Procedure.reason Base example Procedure Reason Codes 📍6.0.0-ballot3 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📍6.0.0-ballot3 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍6.0.0-ballot3 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍6.0.0-ballot3 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍6.0.0-ballot3 FHIR Std.
Procedure.used Base example Device Type 📍6.0.0-ballot3 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-4 error Procedure bodyStructure SHALL only be present if Procedure.bodySite is not present bodySite.exists() implies bodyStructure.empty()
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.trace('id') in %resource.descendants().select(reference | as(uri))) or descendants().where(reference='#' | as(uri)='#').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())
prc-1 error Procedure.performer Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole onBehalfOf.exists() and actor.resolve().exists() implies actor.resolve().where($this is Practitioner or $this is PractitionerRole).empty()

This structure is derived from Procedure

Summary

Must-Support: 1 element

 

Other representations of profile: CSV, Excel, Schematron