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

## Resource Profile: Past procedure performed on patient in Imaging Diagnostic Report

Official URL: https://profiles.ihe.net/RAD/IDR/StructureDefinition/idr-patient-history-procedure | Version: 0.0.1-current
Draft as of 2024-06-25 | Computable Name: IDRPatientHistoryProcedure

A procedure that was performed on the patient in the past.

Usage:

- Refer to this Resource Profile: IDR Patient History

### 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
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
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

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 | Σ C | 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 | Σ C | 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 |  | 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 |  | 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: 1 element

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
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
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

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 | Σ C | 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 | Σ C | 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 |  | 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 |  | 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: 1 element

Other representations of profile: CSV, Excel, Schematron