HL7.FHIR.CL.GRAVITYCL\Procedimiento SDOHCC - Definitions

Is Modifier false

Summary true

4. Procedure.meta

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Short Metadata about the resource

Control 0..1

Meta

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

6. Procedure.implicitRules

Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Short A set of rules under which this content was created

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control 0..1

uri

Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

8. Procedure.language

Definition

The base language in which the resource is written.

Short Language of the resource content

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control 0..1

The codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional Bindings

Purpose

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

10. Procedure.text

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Short Text summary of the resource, for human interpretation

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control 0..1

Narrative

Is Modifier false

Summary false

Alternate Names narrative, html, xhtml, display

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

12. Procedure.contained

Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Short Contained, inline Resources

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control 0..*

Resource

Is Modifier false

Summary false

Alternate Names inline resources, anonymous resources, contained resources

14. Procedure.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())

This element introduces a set of slices on Procedure.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

16. Procedure.extension:pertainsToGoal

Slice Name pertainsToGoal

Definition

Indica que el recurso está relacionado con la medición,logro o progreso hacia la meta/objetivo referenciado.Por ejemplo,un procedimiento para proporcionar vales de alimentos pertenece a la meta/objetivo de lograr seguridad alimentaria.

Short Pertenece a la meta/objetivo de SDOH.

Comments

This extension is limited to subject-specific activity-related resources (events & intents). I.e. This can't be put on Goal or Patient. This association isn't for the purpose of goal management, but for things such as noting that a particular observation result, prescription or other activity is pertinent to the achievement (or possibly non-achievement) of the referenced goal.

Control 0..*

Type Extension(ServiceRequest Pertains To Goal) (Extension Type: Reference(Goal))

Is Modifier false

Must Support true

Requirements

Indica que el procedimiento está relacionado con la meta/objetivo de SDOHCC referenciada.

18. Procedure.extension:pertainsToGoal.id

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Unique id for inter-element referencing

Control 0..1
This element is affected by the following invariants: ele-1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

20. Procedure.extension:pertainsToGoal.extension

Definition

An Extension

Short Extension

Control 0..0

Is Modifier false

Summary false

This element introduces a set of slices on Procedure.extension.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

22. Procedure.extension:pertainsToGoal.url

Definition

Source of the definition for the extension code - a logical name or a URL.

Short identifies the meaning of the extension

Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Control 1..1

uri

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

Fixed Value http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal

24. Procedure.extension:pertainsToGoal.value[x]

Definition

El valor de la extensión debe hacer referencia a un recurso de meta/objetivo.

Short Value of extension

Control 1..1
This element is affected by the following invariants: ext-1

Type Reference(Metas/Objetivos SDOHCC)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Must Support true

Summary false

Requirements

Indica que el procedimiento está relacionado con la meta/objetivo de SDOHCC referenciada.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

26. Procedure.modifierExtension

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensions that cannot be ignored

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them

Summary false

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Names extensions, user content

28. Procedure.identifier

Definition

Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Short External Identifiers for this procedure

Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..*

Identifier

Is Modifier false

Summary true

Requirements

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

30. Procedure.instantiatesCanonical

Definition

The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Short Instantiates FHIR protocol or definition

Control 0..*

Type canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

32. Procedure.instantiatesUri

Definition

The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Short Instantiates external protocol or definition

Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Control 0..*

uri

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

34. Procedure.basedOn

Definition

A reference to a resource that contains details of the request for this procedure.

Short A request for this procedure

Control 0..*

Type Reference(CarePlan, ServiceRequest)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Alternate Names fulfills

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

This element introduces a set of slices on Procedure.basedOn. The slices areUnordered and Open, and can be differentiated using the following discriminators:

profile @ resolve()

36. Procedure.basedOn:SupportedBasedOn

Slice Name SupportedBasedOn

Definition

Una referencia a una solicitud de servicio de SDOHCC que contiene detalles de la solicitud para este procedimiento.

Short Una solicitud de servicio de SDOH para este procedimiento.

Control 0..*

Type Reference(Solicitud de servicio de SDOHCC)

Is Modifier false

Must Support true

Summary true

Requirements

Cuando un procedimiento se basa en una ServiceRequest, Procedure.basedOn debe hacer referencia a instancias que cumplan con el perfil de solicitud de servcio de SDOHCC. Sin embargo,también son posibles referencias a otros tipos de instancias.

Alternate Names fulfills

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

38. Procedure.partOf

Definition

A larger event of which this particular procedure is a component or step.

Short Part of referenced event

Comments

The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Control 0..*

Type Reference(Procedure, Observation, MedicationAdministration)

Is Modifier false

Summary true

Alternate Names container

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

40. Procedure.status

Definition

A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Comments

The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control 1..1

The codes SHALL be taken from EventStatus
(required to http://hl7.org/fhir/ValueSet/event-status|4.0.1)

A code specifying the state of the procedure.

code

Is Modifier true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

42. Procedure.statusReason

Definition

Captures the reason for the current state of the procedure.

Short Reason for current status

Comments

This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

Control 0..1

For example codes, see ProcedureNotPerformedReason(SNOMED-CT)
(example to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason)

A code that identifies the reason a procedure was not performed.

Is Modifier false

Summary true

Alternate Names Suspended Reason, Cancelled Reason

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

44. Procedure.category

Definition

Un código que clasifica el procedimiento para fines de búsqueda, ordenación y visualización (por ejemplo, "Procedimiento de servicio social").

Short Classification of the procedure

Control 0..1

For example codes, see ProcedureCategoryCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-category)

A code that classifies a procedure for searching, sorting and display purposes.

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

46. Procedure.category.id

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

48. Procedure.category.extension

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

This element introduces a set of slices on Procedure.category.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

50. Procedure.category.coding

Definition

A reference to a code defined by a terminology system.

Short Code defined by a terminology system

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control 0..*

Coding

Is Modifier false

Must Support true

Summary true

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

This element introduces a set of slices on Procedure.category.coding. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ $this

52. Procedure.category.coding:SDOH

Slice Name SDOH

Definition

Una categoría de SDOH asignada al procedimiento.

Short Por ejemplo, inseguridad alimentaria | inseguridad en el transporte.

Comments

Control 0..1

The codes SHALL be taken from ValueSet SDOHCC para Categoría SDOH
(required to https://hl7chile.cl/fhir/ig/gravitycl/ValueSet/SDOHCC-ValueSetSDOHCategoryCL)

Códigos para categorías de SDOH de alto nivel.

Coding

Is Modifier false

Must Support true

Summary true

Requirements

Permite codificaciones alternativas dentro de un value set y traducciones a otros sistemas de códigos. Los códigos de este conjunto de valores pueden utilizarse para asignar una categoría de SDOH (por ejemplo, inseguridad alimentaria, inseguridad en el transporte, etc.) a un procedimiento. Se recomienda utilizar los códigos de categoría de SDOH para facilitar la búsqueda de procedimientos de SDOH que aborden condiciones, observaciones, solicitudes de servicio o metas/objetivos de SDOH.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

54. Procedure.category.text

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short Plain text representation of the concept

Comments

Very often the text is the same as a displayName of one of the codings.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

56. Procedure.code

Definition

El procedimiento específico que se realiza. Utilice texto si la naturaleza exacta del procedimiento no puede ser codificada.

Short Identification of the procedure

Control 0..1

The codes SHALL be taken from Códigos de procedimientos CL
(required to https://hl7chile.cl/fhir/ig/gravitycl/ValueSet/cl-core-procedure-code)

Códigos que describen el tipo de procedimiento

Is Modifier false

Summary true

Requirements

0..1 to account for primarily narrative only resources.

Alternate Names type

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

58. Procedure.subject

Definition

The person, animal or group on which the procedure was performed.

Short Who the procedure was performed on

Control 1..1

Type Reference(Patient, Group)

Is Modifier false

Summary true

Alternate Names patient

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

60. Procedure.encounter

Definition

The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Short Encounter created as part of

Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Control 0..1

Type Reference(Encounter)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

62. Procedure.performed[x]

Definition

Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Short When the procedure was performed

Comments

Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Control 0..1

Type Choice of: dateTime, Period, string, Age, Range

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

NOTA: dateTime debería ser "Must Support",pero actualmente las herramientas no lo soportan.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

64. Procedure.recorder

Definition

Individual who recorded the record and takes responsibility for its content.

Short Who recorded the procedure

Control 0..1

Type Reference(Patient, RelatedPerson, Practitioner, PractitionerRole)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

66. Procedure.asserter

Definition

Individual who is making the procedure statement.

Short Person who asserts this procedure

Control 0..1

Type Reference(Patient, RelatedPerson, Practitioner, PractitionerRole)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

68. Procedure.performer

Definition

Limited to "real" people rather than equipment.

Short The people who performed the procedure

Control 0..*

BackboneElement

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

70. Procedure.performer.id

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

72. Procedure.performer.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

74. Procedure.performer.modifierExtension

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

76. Procedure.performer.function

Definition

Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Short Type of performance

Control 0..1

For example codes, see ProcedurePerformerRoleCodes
(example to http://hl7.org/fhir/ValueSet/performer-role)

A code that identifies the role of a performer of the procedure.

Is Modifier false

Summary true

Requirements

Allows disambiguation of the types of involvement of different performers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

78. Procedure.performer.actor

Definition

The practitioner who was involved in the procedure.

Short The reference to the practitioner

Control 1..1

Type Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson, Device)

Is Modifier false

Summary true

Requirements

A reference to Device supports use cases, such as pacemakers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

80. Procedure.performer.onBehalfOf

Definition

The organization the device or practitioner was acting on behalf of.

Short Organization the device or practitioner was acting for

Control 0..1

Type Reference(Organization)

Is Modifier false

Summary false

Requirements

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

82. Procedure.location

Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Short Where the procedure happened

Control 0..1

Type Reference(Location)

Is Modifier false

Summary true

Requirements

Ties a procedure to where the records are likely kept.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

84. Procedure.reasonCode

Definition

The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Short Coded reason procedure performed

Comments

Procedure.reasonCode y Procedure.reasonReference no están destinados a ser duplicativos. Para una única razón, se puede utilizar ya sea Procedure.reasonCode o Procedure.reasonReference. Procedure.reasonCode puede ser un código resumido, o Procedure.reasonReference puede usarse para referirse a una definición muy precisa de la razón utilizando Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Ambos, Procedure.reasonCode y Procedure.reasonReference,pueden usarse si están escribiendo diferentes razones para el procedimiento.

La información representada por Procedure.reasonCode puede superponerse significativamente con la información representada por Procedure.reasonReference. Múltiples enfoques para representar la misma información pueden impactar negativamente la interoperabilidad. Por lo tanto, donde se podría proporcionar información similar ya sea a través de Procedure.reasonCode o Procedure.reasonReference, se recomienda usar Procedure.reasonReference para proporcionar una razón de por qué se realizó un procedimiento.

Control 0..*

For example codes, see ProcedureReasonCodes
(example to http://hl7.org/fhir/ValueSet/procedure-reason)

A code that identifies the reason a procedure is required.

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

86. Procedure.reasonReference

Definition

The justification of why the procedure was performed.

Short The justification that the procedure was performed

Comments

Procedure.reasonCode y Procedure.reasonReference no están destinados a ser duplicativos. Para una única razón, se puede utilizar ya sea Procedure.reasonCode o Procedure.reasonReference. Procedure.reasonCode puede ser un código resumido, o Procedure.reasonReference puede usarse para referirse a una definición muy precisa de la razón utilizando Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Ambos, Procedure.reasonCode y Procedure.reasonReference, pueden usarse si están describiendo diferentes razones para el procedimiento.

Además, consulte los Comentarios para reasonCode.

Control 0..*

Type Reference(Condition, Observation, Procedure, DiagnosticReport, DocumentReference)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

This element introduces a set of slices on Procedure.reasonReference. The slices areUnordered and Open, and can be differentiated using the following discriminators:

profile @ resolve()

88. Procedure.reasonReference:SupportedReasonReference

Slice Name SupportedReasonReference

Definition

The justification of why the procedure was performed.

Short The justification that the procedure was performed

Comments

Procedure.reasonCode y Procedure.reasonReference no están destinados a ser duplicativos. Para una única razón, se puede utilizar ya sea Procedure.reasonCode o Procedure.reasonReference. Procedure.reasonCode puede ser un código resumido, o Procedure.reasonReference puede usarse para referirse a una definición muy precisa de la razón utilizando Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Ambos, Procedure.reasonCode y Procedure.reasonReference, pueden usarse si están describiendo diferentes razones para el procedimiento.

Control 0..*

Type Reference(Condición SDOHCC, Respuesta de Detección de Observación de SDOHCC, Evaluación de Observación de SDOHCC)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Requirements

Cuando un procedimiento está justificado por una o más condiciones u observaciones de SDOH, Procedure.reasonReference debe hacer referencia a instancias que cumplan con el perfil de condición SDOHCC, o uno de los perfiles de observación SDOHCC. Sin embargo, también son posibles referencias a otros tipos de instancias.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

90. Procedure.bodySite

Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Short Target body sites

Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Control 0..*

For example codes, see SNOMEDCTBodyStructures
(example to http://hl7.org/fhir/ValueSet/body-site)

Codes describing anatomical locations. May include laterality.

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

92. Procedure.outcome

Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Short The result of procedure

Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Control 0..1

For example codes, see ProcedureOutcomeCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-outcome)

An outcome of a procedure - whether it was resolved or otherwise.

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

94. Procedure.report

Definition

This could be a histology result, pathology report, surgical report, etc.

Short Any report resulting from the procedure

Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Control 0..*

Type Reference(DiagnosticReport, DocumentReference, Composition)

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

96. Procedure.complication

Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Short Complication following the procedure

Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Control 0..*

For example codes, see Condition/Problem/DiagnosisCodes
(example to http://hl7.org/fhir/ValueSet/condition-code)

Codes describing complications that resulted from a procedure.

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

98. Procedure.complicationDetail

Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Short A condition that is a result of the procedure

Control 0..*

Type Reference(Condition)

Is Modifier false

Summary false

Requirements

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

100. Procedure.followUp

Definition

If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.

Short Instructions for follow up

Control 0..*

For example codes, see ProcedureFollowUpCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-followup)

Specific follow up required for a procedure e.g. removal of sutures.

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

102. Procedure.note

Definition

Any other notes and comments about the procedure.

Short Additional information about the procedure

Control 0..*

Annotation

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

104. Procedure.focalDevice

Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Short Manipulated, implanted, or removed device

Control 0..*

BackboneElement

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

106. Procedure.focalDevice.id

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

108. Procedure.focalDevice.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

110. Procedure.focalDevice.modifierExtension

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

112. Procedure.focalDevice.action

Definition

The kind of change that happened to the device during the procedure.

Short Kind of change to device

Control 0..1

The codes SHOULD be taken from ProcedureDeviceActionCodes
(preferred to http://hl7.org/fhir/ValueSet/device-action)

A kind of change that happened to the device during the procedure.

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

114. Procedure.focalDevice.manipulated

Definition

The device that was manipulated (changed) during the procedure.

Short Device that was changed

Control 1..1

Type Reference(Device)

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

116. Procedure.usedReference

Definition

Identifies medications, devices and any other substance used as part of the procedure.

Short Items used during procedure

Comments

For devices actually implanted or removed, use Procedure.device.

Control 0..*

Type Reference(Device, Medication, Substance)

Is Modifier false

Summary false

Requirements

Used for tracking contamination, etc.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

118. Procedure.usedCode

Definition

Identifies coded items that were used as part of the procedure.

Short Coded items used during the procedure

Comments

For devices actually implanted or removed, use Procedure.device.

Control 0..*

For example codes, see FHIRDeviceTypes
(example to http://hl7.org/fhir/ValueSet/device-kind)

Codes describing items used during a procedure.