HL7 Europe Base and Core FHIR IG
2.0.0 - trial-use 150

HL7 Europe Base and Core FHIR IG, published by HL7 Europe. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/base/ and changes regularly. See the Directory of published versions

## Resource Profile: Procedure (EU core)

Official URL: http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core | Version: 2.0.0
Standards status: Trial-use | Maturity Level: 2 | Computable Name: ProcedureEuCore
Copyright/Legal: Copyright HL7 Europe. Licensed under creative commons public domain (CC0 1.0).

This profile introduces essential constraints and extensions for the Procedure resource that apply across multiple use cases.

Usages:

- Refer to this Profile: Procedure (EU core)
- Examples for this Profile: Procedure/procedure-eu-core-example

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.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the procedure Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Textual representation of the procedure This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recorded |  | 0..1 | dateTime | Date when the procedure was recorded URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Identifier for the procedure
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.
code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedures - IPS (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core)) | Who the procedure was performed on
performed[x] | Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who asserts the procedure
reasonCode | Σ | 0..* | CodeableConcept | Why the procedure was performed (code) Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference | Σ | 0..* | Reference(Condition (EU core) | Observation | Procedure (EU core) | DiagnosticReport | DocumentReference) | Why the procedure was performed (details)
bodySite | Σ C | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) Constraints: eu-bodysite-1
Slices for extension |  |  |  | Content/Rules for all slices
extension:bodySite |  | 0..1 | (Complex) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/bodySite"
value[x] |  | 1..1 | Reference(BodyStructure (EU core)) | Value of extension
outcome | Σ | 0..1 | CodeableConcept | Outcome of the procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
complication |  | 0..* | CodeableConcept | Complications that occurred during the procedure (code) Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail |  | 0..* | Reference(Condition (EU core)) | Complications that occurred during the procedure (details)
note |  | 0..* | Annotation | Additional information about the procedure.
focalDevice |  | 0..* | BackboneElement | Device implanted, removed or otherwise manipulated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
manipulated |  | 1..1 | Reference(Device) | Device that was changed
usedReference |  | 0..* | Reference(Device | Medication (EU core) | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Device used to perform the procedure (code) Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.code | Base | preferred | Procedures - IPS | ⏿2.0.0 | tx.hl7europe.eu
Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std.
Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').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())`
eu-bodysite-1 | error | Procedure.bodySite | Either a body site code or a reference to a BodyStructure resource SHALL be used, but not both. | `(coding.empty() and text.empty()) or extension('http://hl7.org/fhir/StructureDefinition/bodySite').empty()`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from Procedure

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
language |  | 0..1 | code | Language of the procedure
text |  | 0..1 | Narrative | Textual representation of the procedure
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recorded |  | 0..1 | dateTime | Date when the procedure was recorded URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
identifier |  | 0..* | Identifier | Identifier for the procedure
code |  | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedures - IPS (preferred)
subject |  | 1..1 | Reference(Patient (EU core)) | Who the procedure was performed on
performed[x] |  | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed
recorder |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who recorded the procedure
asserter |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who asserts the procedure
performer |  |  |  |
actor |  | 1..1 | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Device | Patient (EU core) | RelatedPerson | Organization (EU core)) | The reference to the practitioner
onBehalfOf |  | 0..1 | Reference(Organization (EU core)) | Organization the device or practitioner was acting for
reasonCode |  | 0..* | CodeableConcept | Why the procedure was performed (code)
reasonReference |  | 0..* | Reference(Condition (EU core) | Observation | Procedure (EU core) | DiagnosticReport | DocumentReference) | Why the procedure was performed (details)
bodySite | C | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) Constraints: eu-bodysite-1
Slices for extension |  |  |  | Content/Rules for all slices
extension:bodySite |  | 0..1 | (Complex) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x] |  | 1..1 | Reference(BodyStructure (EU core)) | Value of extension
outcome |  | 0..1 | CodeableConcept | Outcome of the procedure
complication |  | 0..* | CodeableConcept | Complications that occurred during the procedure (code)
complicationDetail |  | 0..* | Reference(Condition (EU core)) | Complications that occurred during the procedure (details)
note |  | 0..* | Annotation | Additional information about the procedure.
focalDevice |  | 0..* | BackboneElement | Device implanted, removed or otherwise manipulated
usedReference |  | 0..* | Reference(Device | Medication (EU core) | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Device used to perform the procedure (code)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Procedure.code | Base | preferred | Procedures - IPS | ⏿2.0.0 | tx.hl7europe.eu
Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
eu-bodysite-1 | error | Procedure.bodySite | Either a body site code or a reference to a BodyStructure resource SHALL be used, but not both. | `(coding.empty() and text.empty()) or extension('http://hl7.org/fhir/StructureDefinition/bodySite').empty()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
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 procedure Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Textual representation of the procedure This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recorded |  | 0..1 | dateTime | Date when the procedure was recorded URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Identifier for the 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: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedures - IPS (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core)) | Who the procedure was performed on
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
performed[x] | Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who asserts the procedure
performer | Σ | 0..* | BackboneElement | The people who performed the procedure
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 | 1..1 | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Device | Patient (EU core) | RelatedPerson | Organization (EU core)) | The reference to the practitioner
onBehalfOf |  | 0..1 | Reference(Organization (EU core)) | Organization the device or practitioner was acting for
location | Σ | 0..1 | Reference(Location) | Where the procedure happened
reasonCode | Σ | 0..* | CodeableConcept | Why the procedure was performed (code) Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference | Σ | 0..* | Reference(Condition (EU core) | Observation | Procedure (EU core) | DiagnosticReport | DocumentReference) | Why the procedure was performed (details)
bodySite | Σ C | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) Constraints: eu-bodysite-1
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:bodySite |  | 0..1 | (Complex) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/bodySite"
value[x] |  | 1..1 | Reference(BodyStructure (EU core)) | Value of extension
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
outcome | Σ | 0..1 | CodeableConcept | Outcome of the procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (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..* | CodeableConcept | Complications that occurred during the procedure (code) Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail |  | 0..* | Reference(Condition (EU core)) | Complications that occurred during the procedure (details)
followUp |  | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note |  | 0..* | Annotation | Additional information about the procedure.
focalDevice |  | 0..* | BackboneElement | Device implanted, removed or otherwise manipulated
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
usedReference |  | 0..* | Reference(Device | Medication (EU core) | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Device used to perform the procedure (code) Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std.
Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.code | Base | preferred | Procedures - IPS | ⏿2.0.0 | tx.hl7europe.eu
Procedure.performer.​function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std.
Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std.
Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📍4.0.1 | FHIR Std.
Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').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())`
eu-bodysite-1 | error | Procedure.bodySite | Either a body site code or a reference to a BodyStructure resource SHALL be used, but not both. | `(coding.empty() and text.empty()) or extension('http://hl7.org/fhir/StructureDefinition/bodySite').empty()`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from Procedure

Summary

Mandatory: 2 elements

Structures

This structure refers to these other structures:

- Patient (EU core) (http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core)
- PractitionerRole (EU core) (http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core)
- Practitioner (EU core) (http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core)
- Organization (EU core) (http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core)
- Condition (EU core) (http://hl7.eu/fhir/base/StructureDefinition/condition-eu-core)
- Procedure (EU core) (http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core)
- BodyStructure (EU core) (http://hl7.eu/fhir/base/StructureDefinition/bodyStructure-eu-core)
- Medication (EU core) (http://hl7.eu/fhir/base/StructureDefinition/medication-eu-core)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
- http://hl7.org/fhir/StructureDefinition/bodySite

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the procedure Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Textual representation of the procedure This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recorded |  | 0..1 | dateTime | Date when the procedure was recorded URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Identifier for the procedure
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.
code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedures - IPS (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core)) | Who the procedure was performed on
performed[x] | Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who asserts the procedure
reasonCode | Σ | 0..* | CodeableConcept | Why the procedure was performed (code) Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference | Σ | 0..* | Reference(Condition (EU core) | Observation | Procedure (EU core) | DiagnosticReport | DocumentReference) | Why the procedure was performed (details)
bodySite | Σ C | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) Constraints: eu-bodysite-1
Slices for extension |  |  |  | Content/Rules for all slices
extension:bodySite |  | 0..1 | (Complex) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/bodySite"
value[x] |  | 1..1 | Reference(BodyStructure (EU core)) | Value of extension
outcome | Σ | 0..1 | CodeableConcept | Outcome of the procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
complication |  | 0..* | CodeableConcept | Complications that occurred during the procedure (code) Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail |  | 0..* | Reference(Condition (EU core)) | Complications that occurred during the procedure (details)
note |  | 0..* | Annotation | Additional information about the procedure.
focalDevice |  | 0..* | BackboneElement | Device implanted, removed or otherwise manipulated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
manipulated |  | 1..1 | Reference(Device) | Device that was changed
usedReference |  | 0..* | Reference(Device | Medication (EU core) | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Device used to perform the procedure (code) Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.code | Base | preferred | Procedures - IPS | ⏿2.0.0 | tx.hl7europe.eu
Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std.
Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').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())`
eu-bodysite-1 | error | Procedure.bodySite | Either a body site code or a reference to a BodyStructure resource SHALL be used, but not both. | `(coding.empty() and text.empty()) or extension('http://hl7.org/fhir/StructureDefinition/bodySite').empty()`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from Procedure

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
language |  | 0..1 | code | Language of the procedure
text |  | 0..1 | Narrative | Textual representation of the procedure
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recorded |  | 0..1 | dateTime | Date when the procedure was recorded URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
identifier |  | 0..* | Identifier | Identifier for the procedure
code |  | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedures - IPS (preferred)
subject |  | 1..1 | Reference(Patient (EU core)) | Who the procedure was performed on
performed[x] |  | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed
recorder |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who recorded the procedure
asserter |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who asserts the procedure
performer |  |  |  |
actor |  | 1..1 | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Device | Patient (EU core) | RelatedPerson | Organization (EU core)) | The reference to the practitioner
onBehalfOf |  | 0..1 | Reference(Organization (EU core)) | Organization the device or practitioner was acting for
reasonCode |  | 0..* | CodeableConcept | Why the procedure was performed (code)
reasonReference |  | 0..* | Reference(Condition (EU core) | Observation | Procedure (EU core) | DiagnosticReport | DocumentReference) | Why the procedure was performed (details)
bodySite | C | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) Constraints: eu-bodysite-1
Slices for extension |  |  |  | Content/Rules for all slices
extension:bodySite |  | 0..1 | (Complex) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
value[x] |  | 1..1 | Reference(BodyStructure (EU core)) | Value of extension
outcome |  | 0..1 | CodeableConcept | Outcome of the procedure
complication |  | 0..* | CodeableConcept | Complications that occurred during the procedure (code)
complicationDetail |  | 0..* | Reference(Condition (EU core)) | Complications that occurred during the procedure (details)
note |  | 0..* | Annotation | Additional information about the procedure.
focalDevice |  | 0..* | BackboneElement | Device implanted, removed or otherwise manipulated
usedReference |  | 0..* | Reference(Device | Medication (EU core) | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Device used to perform the procedure (code)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Procedure.code | Base | preferred | Procedures - IPS | ⏿2.0.0 | tx.hl7europe.eu
Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
eu-bodysite-1 | error | Procedure.bodySite | Either a body site code or a reference to a BodyStructure resource SHALL be used, but not both. | `(coding.empty() and text.empty()) or extension('http://hl7.org/fhir/StructureDefinition/bodySite').empty()`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
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 procedure Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Textual representation of the procedure This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recorded |  | 0..1 | dateTime | Date when the procedure was recorded URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded Constraints: ext-1
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Identifier for the 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: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedures - IPS (preferred)
subject | Σ | 1..1 | Reference(Patient (EU core)) | Who the procedure was performed on
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
performed[x] | Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | The person or organization who asserts the procedure
performer | Σ | 0..* | BackboneElement | The people who performed the procedure
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 | 1..1 | Reference(PractitionerRole (EU core) | Practitioner (EU core) | Device | Patient (EU core) | RelatedPerson | Organization (EU core)) | The reference to the practitioner
onBehalfOf |  | 0..1 | Reference(Organization (EU core)) | Organization the device or practitioner was acting for
location | Σ | 0..1 | Reference(Location) | Where the procedure happened
reasonCode | Σ | 0..* | CodeableConcept | Why the procedure was performed (code) Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference | Σ | 0..* | Reference(Condition (EU core) | Observation | Procedure (EU core) | DiagnosticReport | DocumentReference) | Why the procedure was performed (details)
bodySite | Σ C | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) Constraints: eu-bodysite-1
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:bodySite |  | 0..1 | (Complex) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/bodySite"
value[x] |  | 1..1 | Reference(BodyStructure (EU core)) | Value of extension
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
outcome | Σ | 0..1 | CodeableConcept | Outcome of the procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (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..* | CodeableConcept | Complications that occurred during the procedure (code) Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail |  | 0..* | Reference(Condition (EU core)) | Complications that occurred during the procedure (details)
followUp |  | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note |  | 0..* | Annotation | Additional information about the procedure.
focalDevice |  | 0..* | BackboneElement | Device implanted, removed or otherwise manipulated
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
usedReference |  | 0..* | Reference(Device | Medication (EU core) | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Device used to perform the procedure (code) Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std.
Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std.
Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.code | Base | preferred | Procedures - IPS | ⏿2.0.0 | tx.hl7europe.eu
Procedure.performer.​function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std.
Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std.
Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std.
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | preferred | Procedure Device Action Codes | 📍4.0.1 | FHIR Std.
Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
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 in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').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())`
eu-bodysite-1 | error | Procedure.bodySite | Either a body site code or a reference to a BodyStructure resource SHALL be used, but not both. | `(coding.empty() and text.empty()) or extension('http://hl7.org/fhir/StructureDefinition/bodySite').empty()`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from Procedure

Summary

Mandatory: 2 elements

Structures

This structure refers to these other structures:

- Patient (EU core) (http://hl7.eu/fhir/base/StructureDefinition/patient-eu-core)
- PractitionerRole (EU core) (http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core)
- Practitioner (EU core) (http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core)
- Organization (EU core) (http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core)
- Condition (EU core) (http://hl7.eu/fhir/base/StructureDefinition/condition-eu-core)
- Procedure (EU core) (http://hl7.eu/fhir/base/StructureDefinition/procedure-eu-core)
- BodyStructure (EU core) (http://hl7.eu/fhir/base/StructureDefinition/bodyStructure-eu-core)
- Medication (EU core) (http://hl7.eu/fhir/base/StructureDefinition/medication-eu-core)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
- http://hl7.org/fhir/StructureDefinition/bodySite

Maturity: 2

Other representations of profile: CSV, Excel, Schematron