AU Core Implementation Guide
1.0.0-ci-build - CI Build Australia flag

AU Core Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-core/ and changes regularly. See the Directory of published versions

Resource Profile: AU Core Procedure

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-procedure Version: 1.0.0-ci-build
Standards status: Draft Maturity Level: 1 Computable Name: AUCoreProcedure

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for a Procedure resource to record, search, and fetch procedures associated with a patient. It is based on the AU Base Procedure profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Procedure resource when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

See Comparison with other national and international IGs for a comparison between AU Core profiles and profiles in other implementation guides.

Usage scenarios

The following are supported usage scenarios for this profile:

  • Query for procedures performed on a patient
  • Record or update a record of a procedure performed on a patient

Profile specific implementation guidance

  • Procedure.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • The use of coding can vary significantly across systems, requesters need to understand that they may encounter codes they do not recognise and be prepared to handle those resources appropriately. Responders SHOULD populate Procedure.code.text and/or Procedure.code.coding.display so that requesters can at least display the procedure even if the requester does not recognise the code supplied.
  • Procedure.code contains the identification of the procedure which may include body site information. Where a system has information not supported by the coding in Procedure.code.coding (e.g. body site, laterality and other qualification of procedure coding terms) that information SHOULD be supplied in Procedure.code.text
  • The Procedure resource can represent a clinical indication with Procedure.reasonCode, or a reference with Procedure.reasonReference to a Condition or other resource.
    • Although both are marked as Must Support, responders are not required to support both a code and a reference, but they SHALL support at least one of these elements
    • A requester SHALL support both elements
  • A procedure including an implantable device is recommended to use Procedure.focalDevice with a reference to a Device resource

Usage:

Changes since version 1.0.0-ballot:

  • The data elements list has changed

    • Formal Views of Profile Content

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

    This structure is derived from AUBaseProcedure

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure 0..* AUBaseProcedure A procedure in an Australian healthcare context
    ... status SO 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... code SO 1..1 CodeableConcept Identification of the procedure
    Binding: Procedure . (extensible)
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... subject SO 1..1 Reference(AU Core Patient) Who the procedure was performed on
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... performed[x] SO 0..1 dateTime, Period, string, Age, Range When the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonCode SO 0..* CodeableConcept Coded reason procedure performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonReference SO 0..* Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) The justification that the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... bodySite C 0..* CodeableConcept Target body sites
    Binding: Body Site . (extensible)
    au-core-pro-01: If a coded body site is provided, at least one code shall be from SNOMED CT

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Procedure.codeextensibleProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
    Procedure.bodySiteextensibleBodySite .
    https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

    Constraints

    IdGradePath(s)DetailsRequirements
    au-core-pro-01errorProcedure.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
    : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure 0..* AUBaseProcedure A procedure in an Australian healthcare context
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension Content/Rules for all slices
    .... targetBodyStructure 0..* Reference(BodyStructure) The target point for this procedure
    URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... code SOΣ 1..1 CodeableConcept Identification of the procedure
    Binding: Procedure . (extensible)
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... subject SOΣ 1..1 Reference(AU Core Patient) Who the procedure was performed on
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... encounter SOΣ 0..1 Reference(AU Core Encounter) Encounter created as part of
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... performed[x] SOΣ 0..1 When the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    .... performedDateTime dateTime
    .... performedPeriod Period
    .... performedString string
    .... performedAge Age
    .... performedRange Range
    ... reasonCode SOΣ 0..* CodeableConcept Coded reason procedure performed
    Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonReference SOΣ 0..* Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) The justification that the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... bodySite ΣC 0..* CodeableConcept Target body sites
    Binding: Body Site . (extensible)
    au-core-pro-01: If a coded body site is provided, at least one code shall be from SNOMED CT

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status|4.0.1
    from the FHIR Standard
    Procedure.codeextensibleProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
    Procedure.reasonCodeexampleProcedureReasonCodes
    http://hl7.org/fhir/ValueSet/procedure-reason
    from the FHIR Standard
    Procedure.bodySiteextensibleBodySite .
    https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

    Constraints

    IdGradePath(s)DetailsRequirements
    au-core-pro-01errorProcedure.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
    : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure 0..* AUBaseProcedure A procedure in an Australian healthcare context
    ... 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: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... targetBodyStructure 0..* Reference(BodyStructure) The target point for this procedure
    URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
    ... modifierExtension ?! 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 ?!SOΣ 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.

    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... 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 SOΣ 1..1 CodeableConcept Identification of the procedure
    Binding: Procedure . (extensible)
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... subject SOΣ 1..1 Reference(AU Core Patient) Who the procedure was performed on
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... encounter SOΣ 0..1 Reference(AU Core Encounter) Encounter created as part of
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... performed[x] SOΣ 0..1 When the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    .... performedDateTime dateTime
    .... performedPeriod Period
    .... performedString string
    .... performedAge Age
    .... performedRange Range
    ... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
    ... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this 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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
    .... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
    ... location Σ 0..1 Reference(Location) Where the procedure happened
    ... reasonCode SOΣ 0..* CodeableConcept Coded reason procedure performed
    Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonReference SOΣ 0..* Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) The justification that the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... bodySite ΣC 0..* CodeableConcept Target body sites
    Binding: Body Site . (extensible)
    au-core-pro-01: If a coded body site is provided, at least one code shall be from SNOMED CT
    ... outcome Σ 0..1 CodeableConcept The result of 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 Complication following the procedure
    Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


    ... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
    ... 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 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
    ... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
    ... usedCode 0..* CodeableConcept Coded items used during the procedure
    Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status|4.0.1
    from the FHIR Standard
    Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
    http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
    from the FHIR Standard
    Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-category
    from the FHIR Standard
    Procedure.codeextensibleProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
    Procedure.performer.functionexampleProcedurePerformerRoleCodes
    http://hl7.org/fhir/ValueSet/performer-role
    from the FHIR Standard
    Procedure.reasonCodeexampleProcedureReasonCodes
    http://hl7.org/fhir/ValueSet/procedure-reason
    from the FHIR Standard
    Procedure.bodySiteextensibleBodySite .
    https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
    Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-outcome
    from the FHIR Standard
    Procedure.complicationexampleCondition/Problem/DiagnosisCodes
    http://hl7.org/fhir/ValueSet/condition-code
    from the FHIR Standard
    Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-followup
    from the FHIR Standard
    Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
    http://hl7.org/fhir/ValueSet/device-action
    from the FHIR Standard
    Procedure.usedCodeexampleFHIRDeviceTypes
    http://hl7.org/fhir/ValueSet/device-kind
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    au-core-pro-01errorProcedure.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
    : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    Differential View

    This structure is derived from AUBaseProcedure

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure 0..* AUBaseProcedure A procedure in an Australian healthcare context
    ... status SO 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... code SO 1..1 CodeableConcept Identification of the procedure
    Binding: Procedure . (extensible)
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... subject SO 1..1 Reference(AU Core Patient) Who the procedure was performed on
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... performed[x] SO 0..1 dateTime, Period, string, Age, Range When the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonCode SO 0..* CodeableConcept Coded reason procedure performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonReference SO 0..* Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) The justification that the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... bodySite C 0..* CodeableConcept Target body sites
    Binding: Body Site . (extensible)
    au-core-pro-01: If a coded body site is provided, at least one code shall be from SNOMED CT

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    Procedure.codeextensibleProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
    Procedure.bodySiteextensibleBodySite .
    https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

    Constraints

    IdGradePath(s)DetailsRequirements
    au-core-pro-01errorProcedure.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
    : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure 0..* AUBaseProcedure A procedure in an Australian healthcare context
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension Content/Rules for all slices
    .... targetBodyStructure 0..* Reference(BodyStructure) The target point for this procedure
    URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... code SOΣ 1..1 CodeableConcept Identification of the procedure
    Binding: Procedure . (extensible)
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... subject SOΣ 1..1 Reference(AU Core Patient) Who the procedure was performed on
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... encounter SOΣ 0..1 Reference(AU Core Encounter) Encounter created as part of
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... performed[x] SOΣ 0..1 When the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    .... performedDateTime dateTime
    .... performedPeriod Period
    .... performedString string
    .... performedAge Age
    .... performedRange Range
    ... reasonCode SOΣ 0..* CodeableConcept Coded reason procedure performed
    Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonReference SOΣ 0..* Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) The justification that the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... bodySite ΣC 0..* CodeableConcept Target body sites
    Binding: Body Site . (extensible)
    au-core-pro-01: If a coded body site is provided, at least one code shall be from SNOMED CT

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status|4.0.1
    from the FHIR Standard
    Procedure.codeextensibleProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
    Procedure.reasonCodeexampleProcedureReasonCodes
    http://hl7.org/fhir/ValueSet/procedure-reason
    from the FHIR Standard
    Procedure.bodySiteextensibleBodySite .
    https://healthterminologies.gov.au/fhir/ValueSet/body-site-1

    Constraints

    IdGradePath(s)DetailsRequirements
    au-core-pro-01errorProcedure.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
    : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. Procedure 0..* AUBaseProcedure A procedure in an Australian healthcare context
    ... 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: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... targetBodyStructure 0..* Reference(BodyStructure) The target point for this procedure
    URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
    ... modifierExtension ?! 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 ?!SOΣ 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.

    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... 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 SOΣ 1..1 CodeableConcept Identification of the procedure
    Binding: Procedure . (extensible)
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... subject SOΣ 1..1 Reference(AU Core Patient) Who the procedure was performed on
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... encounter SOΣ 0..1 Reference(AU Core Encounter) Encounter created as part of
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... performed[x] SOΣ 0..1 When the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    .... performedDateTime dateTime
    .... performedPeriod Period
    .... performedString string
    .... performedAge Age
    .... performedRange Range
    ... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
    ... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this 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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
    .... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
    ... location Σ 0..1 Reference(Location) Where the procedure happened
    ... reasonCode SOΣ 0..* CodeableConcept Coded reason procedure performed
    Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... reasonReference SOΣ 0..* Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) The justification that the procedure was performed
    ObligationsActor
    SHALL:populate-if-known AU Core Responder
    SHALL:no-error AU Core Requester
    ... bodySite ΣC 0..* CodeableConcept Target body sites
    Binding: Body Site . (extensible)
    au-core-pro-01: If a coded body site is provided, at least one code shall be from SNOMED CT
    ... outcome Σ 0..1 CodeableConcept The result of 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 Complication following the procedure
    Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


    ... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
    ... 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 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
    ... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
    ... usedCode 0..* CodeableConcept Coded items used during the procedure
    Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    Procedure.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Procedure.statusrequiredEventStatus
    http://hl7.org/fhir/ValueSet/event-status|4.0.1
    from the FHIR Standard
    Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
    http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
    from the FHIR Standard
    Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-category
    from the FHIR Standard
    Procedure.codeextensibleProcedure .
    https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
    Procedure.performer.functionexampleProcedurePerformerRoleCodes
    http://hl7.org/fhir/ValueSet/performer-role
    from the FHIR Standard
    Procedure.reasonCodeexampleProcedureReasonCodes
    http://hl7.org/fhir/ValueSet/procedure-reason
    from the FHIR Standard
    Procedure.bodySiteextensibleBodySite .
    https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
    Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-outcome
    from the FHIR Standard
    Procedure.complicationexampleCondition/Problem/DiagnosisCodes
    http://hl7.org/fhir/ValueSet/condition-code
    from the FHIR Standard
    Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
    http://hl7.org/fhir/ValueSet/procedure-followup
    from the FHIR Standard
    Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
    http://hl7.org/fhir/ValueSet/device-action
    from the FHIR Standard
    Procedure.usedCodeexampleFHIRDeviceTypes
    http://hl7.org/fhir/ValueSet/device-kind
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    au-core-pro-01errorProcedure.bodySiteIf a coded body site is provided, at least one code shall be from SNOMED CT
    : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()
    dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceProcedureA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU Core CapabilityStatements for a complete list of supported RESTful interactions for this IG.

    FHIR search operations are described here and the syntax used to describe AU Core interactions is defined here.

    Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”. A few items are marked as MAY in this implementation guide to highlight their potential relevance.

    Parameter(s) Conformance Type(s) Requirements (when used alone or in combination)
    patient SHALL reference The requester SHALL provide at least an id value and MAY provide both the Type and id values. The responder SHALL support both.
    patient+date SHALL reference+date
    patient+code+date SHOULD reference+token+date
    patient.identifier SHOULD reference.token The requester SHALL provide both the system and code values. The responder SHALL support both.

    The requester SHOULD support search using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The responder SHOULD support search using the using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile.
    patient+status SHOULD reference+token
    code MAY token The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both.

    The requester SHOULD support multipleOr. The responder SHOULD support multipleOr.
    date MAY date A requester SHALL provide a value precise to the second + time offset. A responder SHALL support a value precise to the second + time offset.

    The requester SHALL support these search comparators gt, lt, ge, le. The responder SHALL support these search comparators gt, lt, ge, le.

    The requester SHOULD support multipleAnd, and if multipleAnd is supported, SHALL support the search comparators gt, lt, ge, le. The responder SHOULD support multipleAnd, and if multipleAnd is supported, SHALL support the search comparators gt, lt, ge, le.
    status MAY token The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both.

    The requester SHALL support multipleOr. The responder SHALL support multipleOr.

    Mandatory Search Parameters

    The following search parameters and search parameter combinations SHALL be supported:

    1. SHALL support searching using the patient search parameter:
      • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

      GET [base]/Procedure?patient={Type/}[id] or optionallyGET [base]/Procedure?patient.identifier=[system|][code]

      Example:

      1. GET [base]/Procedure?patient=5678
      2. GET [base]/Procedure?patient.identifier=http://ns.electronichealth.net.au/id/medicare-number|32788511952
      3. GET [base]/Procedure?patient.identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608833357361

      Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient (how to search by reference and how to search by token)

    2. SHALL support searching using the combination of the patient and date search parameters:
      • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
      • SHALL support these date comparators: gt,lt,ge,le
      • SHOULD support multipleAnd search on date (e.g.date=[date]&date=[date]]&...), and if multipleAnd is supported, SHALL support the search comparators gt,lt,ge,le GET [base]/Procedure?patient={Type/}[id]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/Procedure?patient=5678&date=ge2020-01-01T00:00:00Z
      2. GET [base]/Procedure?patient.identifier=http://example.org/fhir/mrn|12345&date=ge2020-01-01T00:00:00Z

      Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date (how to search by reference and how to search by date)

    Optional Search Parameters

    The following search parameters and search parameter combinations SHOULD be supported:

    1. SHOULD support searching using the combination of the patient and code and date search parameters:
      • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
      • SHOULD support multipleOr search on code (e.g.code={system|}[code],{system|}[code],...)
      • SHALL support these date comparators: gt,lt,ge,le
      • SHOULD support multipleAnd search on date (e.g.date=[date]&date=[date]]&...), and if multipleAnd is supported, SHALL support the search comparators gt,lt,ge,le

      GET [base]/Procedure?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/Procedure?patient=5678&code=http://snomed.info/sct|26782000,http://snomed.info/sct|36969009&date=ge2020-01-01T00:00:00Z
      2. GET [base]/Procedure?patient.identifier=http://example.org/fhir/mrn|12345&code=http://snomed.info/sct|26782000,http://snomed.info/sct|36969009&date=ge2020-01-01T00:00:00Z

      Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date and procedure code(s). SHOULD support search by multiple codes. (how to search by reference and how to search by token and how to search by date)

    2. SHOULD support searching using the combination of the patient and status search parameters:
      • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code]
      • SHALL support multipleOr search on status (e.g.status={system|}[code],{system|}[code],...)

      GET [base]/Procedure?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

      Example:

      1. GET [base]/Procedure?patient=5678&status=completed

      Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and status (how to search by reference and how to search by token)