FHIR CI-Build

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
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Patient Care icon Work GroupMaturity Level: 3 Trial UseSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the Procedure resource.

Procedure
Element IdProcedure
Definition

An action that is or was performed on or for a patient, practitioner, device, organization, or location. For example, this can be a physical intervention on a patient like an operation, or less invasive like long term services, counseling, or hypnotherapy. This can be a quality or safety inspection for a location, organization, or device. This can be an accreditation procedure on a practitioner for licensing.

Short DisplayAn action that is being or was performed on an individual or entity
Cardinality0..*
TypeDomainResource
Summaryfalse
Procedure.identifier
Element IdProcedure.identifier
Definition

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

Short DisplayExternal Identifiers for this procedure
NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

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

Summarytrue
Comments

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

Procedure.instantiatesCanonical
Element IdProcedure.instantiatesCanonical
Definition

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

Short DisplayInstantiates FHIR protocol or definition
Cardinality0..*
Typecanonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)
Summarytrue
Procedure.instantiatesUri
Element IdProcedure.instantiatesUri
Definition

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

Short DisplayInstantiates external protocol or definition
Cardinality0..*
Typeuri
Summarytrue
Comments

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

Procedure.basedOn
Element IdProcedure.basedOn
Definition

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

Short DisplayA request for this procedure
Cardinality0..*
TypeReference(CarePlan | ServiceRequest)
Alternate Namesfulfills
Summarytrue
Procedure.partOf
Element IdProcedure.partOf
Definition

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

Short DisplayPart of referenced event
Cardinality0..*
TypeReference(Procedure | Observation | MedicationAdministration)
Alternate Namescontainer
Summarytrue
Comments

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

Procedure.status
Element IdProcedure.status
Definition

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

Short Displaypreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Cardinality1..1
Terminology BindingEventStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

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

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

Procedure.statusReason
Element IdProcedure.statusReason
Definition

Captures the reason for the current state of the procedure.

Short DisplayReason for current status
Cardinality0..1
Terminology BindingProcedure Not Performed Reason (SNOMED-CT) (Example)
TypeCodeableConcept
Alternate NamesSuspended Reason; Cancelled Reason
Summarytrue
Comments

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

Procedure.category
Element IdProcedure.category
Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Short DisplayClassification of the procedure
Cardinality0..*
Terminology BindingProcedure Category Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Procedure.code
Element IdProcedure.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Short DisplayIdentification of the procedure
Cardinality0..1
Terminology BindingProcedure Codes (SNOMED CT) (Example)
TypeCodeableConcept
Requirements

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

Alternate Namestype
Summarytrue
Procedure.subject
Element IdProcedure.subject
Definition

On whom or on what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure.

Short DisplayIndividual or entity the procedure was performed on
Cardinality1..1
TypeReference(Patient | Group | Device | Practitioner | Organization | Location)
Alternate Namespatient
Summarytrue
Procedure.focus
Element IdProcedure.focus
Definition

Who is the target of the procedure when it is not the subject of record only. If focus is not present, then subject is the focus. If focus is present and the subject is one of the targets of the procedure, include subject as a focus as well. If focus is present and the subject is not included in focus, it implies that the procedure was only targeted on the focus. For example, when a caregiver is given education for a patient, the caregiver would be the focus and the procedure record is associated with the subject (e.g. patient). For example, use focus when recording the target of the education, training, or counseling is the parent or relative of a patient.

Short DisplayWho is the target of the procedure when it is not the subject of record only
Cardinality0..1
TypeReference(Patient | Group | RelatedPerson | Practitioner | Organization | CareTeam | PractitionerRole)
Summarytrue
Procedure.encounter
Element IdProcedure.encounter
Definition

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

Short DisplayThe Encounter during which this Procedure was created
Cardinality0..1
TypeReference(Encounter)
Summarytrue
Comments

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

Procedure.occurrence[x]
Element IdProcedure.occurrence[x]
Definition

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

Short DisplayWhen the procedure occurred or is occurring
Cardinality0..1
TypedateTime|Period|string|Age|Range|Timing
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Summarytrue
Comments

This indicates when the procedure actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this Procedure is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds.

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

Procedure.recorded
Element IdProcedure.recorded
Definition

The date the occurrence of the procedure was first captured in the record regardless of Procedure.status (potentially after the occurrence of the event).

Short DisplayWhen the procedure was first captured in the subject's record
Cardinality0..1
TypedateTime
Summarytrue
Procedure.recorder
Element IdProcedure.recorder
Definition

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

Short DisplayWho recorded the procedure
Cardinality0..1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole)
Summarytrue
Procedure.reported[x]
Element IdProcedure.reported[x]
Definition

Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the source of the report.

Short DisplayReported rather than primary record
Cardinality0..1
Typeboolean|Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
[x] NoteSee Choice of Datatypes for further information about how to use [x]
Requirements

Reported data may have different rules on editing and may be visually distinguished from primary data.

Alternate Namesinformer
Summarytrue
Procedure.performer
Element IdProcedure.performer
Definition

Limited to "real" people rather than equipment.

Short DisplayThe people who performed the procedure
Cardinality0..*
Summarytrue
Procedure.performer.function
Element IdProcedure.performer.function
Definition

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

Short DisplayType of performance
Cardinality0..1
Terminology BindingProcedure Performer Role Codes (Example)
TypeCodeableConcept
Requirements

Allows disambiguation of the types of involvement of different performers.

Summarytrue
Procedure.performer.actor
Element IdProcedure.performer.actor
Definition

Indicates who or what performed the procedure.

Short DisplayWho performed the procedure
Cardinality1..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | CareTeam | HealthcareService)
Requirements

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

Summarytrue
Procedure.performer.onBehalfOf
Element IdProcedure.performer.onBehalfOf
Definition

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

Short DisplayOrganization the device or practitioner was acting for
Cardinality0..1
TypeReference(Organization)
Requirements

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

Summaryfalse
Procedure.performer.period
Element IdProcedure.performer.period
Definition

Time period during which the performer performed the procedure.

Short DisplayWhen the performer performed the procedure
Cardinality0..1
TypePeriod
Summaryfalse
Procedure.location
Element IdProcedure.location
Definition

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

Short DisplayWhere the procedure happened
Cardinality0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Summarytrue
Procedure.reason
Element IdProcedure.reason
Definition

The coded reason or reference why the procedure was performed. This may be a coded entity of some type, be present as text, or be a reference to one of several resources that justify the procedure.

Short DisplayThe justification that the procedure was performed
Cardinality0..*
Terminology BindingProcedure Reason Codes (Example)
TypeCodeableReference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
Summarytrue
Comments

Use Procedure.reason.concept when a code sufficiently describes the reason. Use Procedure.reason.reference when referencing a resource, which allows more information to be conveyed, such as onset date. For a single Procedure.reason, if both Procedure.reason.concept and Procedure.reason.reference are present, they are expected to be consistent with each other.

Procedure.bodySite
Element IdProcedure.bodySite
Definition

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

Short DisplayTarget body sites
Cardinality0..*
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summarytrue
Comments

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

Procedure.outcome
Element IdProcedure.outcome
Definition

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

Short DisplayThe result of procedure
Cardinality0..1
Terminology BindingProcedure Outcome Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Comments

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

Procedure.report
Element IdProcedure.report
Definition

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

Short DisplayAny report resulting from the procedure
Cardinality0..*
TypeReference(DiagnosticReport | DocumentReference | Composition)
Summaryfalse
Comments

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

Procedure.complication
Element IdProcedure.complication
Definition

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

Short DisplayComplication following the procedure
Cardinality0..*
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableReference(Condition)
Summaryfalse
Comments

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

Procedure.followUp
Element IdProcedure.followUp
Definition

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

Short DisplayInstructions for follow up
Cardinality0..*
Terminology BindingProcedure Follow up Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summaryfalse
Procedure.note
Element IdProcedure.note
Definition

Any other notes and comments about the procedure.

Short DisplayAdditional information about the procedure
Cardinality0..*
TypeAnnotation
Summaryfalse
Procedure.focalDevice
Element IdProcedure.focalDevice
Definition

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

Short DisplayManipulated, implanted, or removed device
Cardinality0..*
Summaryfalse
Procedure.focalDevice.action
Element IdProcedure.focalDevice.action
Definition

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

Short DisplayKind of change to device
Cardinality0..1
Terminology BindingProcedure Device Action Codes (Preferred)
TypeCodeableConcept
Summaryfalse
Procedure.focalDevice.manipulated
Element IdProcedure.focalDevice.manipulated
Definition

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

Short DisplayDevice that was changed
Cardinality1..1
TypeReference(Device)
Summaryfalse
Procedure.used
Element IdProcedure.used
Definition

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

Short DisplayItems used during procedure
Cardinality0..*
Terminology BindingDevice Type (Example)
TypeCodeableReference(Device | Medication | Substance | BiologicallyDerivedProduct)
Requirements

Used for tracking contamination, etc.

Summaryfalse
Comments

For devices actually implanted or removed, use Procedure.focalDevice.manipulated.

Procedure.supportingInfo
Element IdProcedure.supportingInfo
Definition

Other resources from the patient record that may be relevant to the procedure. The information from these resources was either used to create the instance or is provided to help with its interpretation. This extension should not be used if more specific inline elements or extensions are available.

Short DisplayExtra information relevant to the procedure
Cardinality0..*
TypeReference(Any)
Summaryfalse