The model provides basic information about a procedure performed on or for a patient. This includes surgical, therapeutic, and diagnostic procedures, as well as specimen collection. The model does not cover procedures in the planning stage.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author responsible for the provided information.

Date and optionally time of authoring/issuing

Status of the procedure (e.g. completed, on hold, stopped)

HL7 Event Status

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Concept code and display name identifying the type of procedure

SNOMED CT

Date and time of the procedure or interval of its performance

Actors who performed the procedure (only main responsible actors expected)

Target body site of the procedure. Laterality may be included as a qualifier of the body site.

The reason the procedure was performed. This may be a concept from a terminology or a reference to a specific instance that describes the reason.

SNOMED CT, ICD-10, Orphacode

The immediate result of the procedure (e.g. successful, unsuccessful). This does not include assessment over a longer period of time.

SNOMED CT

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

ICD-10, SNOMED CT

Device used to perform the procedure

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

Additional information about the procedure

The model provides basic information about a procedure performed on or for a patient. This includes surgical, therapeutic, and diagnostic procedures, as well as specimen collection. The model does not cover procedures in the planning stage.

Author responsible for the provided information.

Status of the procedure (e.g. completed, on hold, stopped)

HL7 Event Status

Concept code and display name identifying the type of procedure

SNOMED CT

Date and time of the procedure or interval of its performance

Actors who performed the procedure (only main responsible actors expected)

Target body site of the procedure. Laterality may be included as a qualifier of the body site.

The reason the procedure was performed. This may be a concept from a terminology or a reference to a specific instance that describes the reason.

SNOMED CT, ICD-10, Orphacode

The immediate result of the procedure (e.g. successful, unsuccessful). This does not include assessment over a longer period of time.

SNOMED CT

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

ICD-10, SNOMED CT

Device used to perform the procedure

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

Additional information about the procedure

The model provides basic information about a procedure performed on or for a patient. This includes surgical, therapeutic, and diagnostic procedures, as well as specimen collection. The model does not cover procedures in the planning stage.

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author responsible for the provided information.

Date and optionally time of authoring/issuing

Status of the procedure (e.g. completed, on hold, stopped)

HL7 Event Status

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Concept code and display name identifying the type of procedure

SNOMED CT

Date and time of the procedure or interval of its performance

Actors who performed the procedure (only main responsible actors expected)

Target body site of the procedure. Laterality may be included as a qualifier of the body site.

The reason the procedure was performed. This may be a concept from a terminology or a reference to a specific instance that describes the reason.

SNOMED CT, ICD-10, Orphacode

The immediate result of the procedure (e.g. successful, unsuccessful). This does not include assessment over a longer period of time.

SNOMED CT

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

ICD-10, SNOMED CT

Device used to perform the procedure

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

Additional information about the procedure