Release 4 5 Preview #3
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Patient Care Work Group Maturity Level : 3   Trial Use Security Category : Patient Compartments : Encounter , Patient , Practitioner , RelatedPerson

Detailed Descriptions for the elements in the Procedure resource.

Type CodeableConcept Comments For devices actually implanted or removed, use Procedure.device.
Procedure
Element Id Procedure
Definition

An action that is or was performed on or for a patient. This 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.

Cardinality 0..*
Type DomainResource
Procedure.identifier
Element Id Procedure.identifier
Definition

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

Note This is a business identifier, not a resource identifier (see discussion )
Cardinality 0..*
Type Identifier
Requirements

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

Summary true
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 Id Procedure.instantiatesCanonical
Definition

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

Cardinality 0..*
Type canonical ( PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire )
Summary true
Procedure.instantiatesUri
Element Id Procedure.instantiatesUri
Definition

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

Cardinality 0..*
Type uri
Summary true
Comments

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

Procedure.basedOn
Element Id Procedure.basedOn
Definition

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

Cardinality 0..*
Type Reference ( CarePlan | ServiceRequest )
Patterns Reference(CarePlan,ServiceRequest): Common patterns = Request
Alternate Names fulfills
Summary true
Procedure.partOf
Element Id Procedure.partOf
Definition

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

Cardinality 0..*
Type Reference ( Procedure | Observation | MedicationAdministration )
Patterns Reference(Procedure,Observation,MedicationAdministration): Common patterns = Event
Alternate Names container
Summary true
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 Id Procedure.status
Definition

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

Cardinality 1..1
Terminology Binding EventStatus ( Required )
Type code
Is Modifier true (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)
Summary true
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 Id Procedure.statusReason
Definition

Captures the reason for the current state of the procedure.

Cardinality 0..1
Terminology Binding Procedure Not Performed Reason (SNOMED-CT) ( Example )
Type CodeableConcept
Alternate Names Suspended Reason; Cancelled Reason
Summary true
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 Id Procedure.category
Definition

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

Cardinality 0..1 0..*
Terminology Binding Procedure Category Codes (SNOMED CT) ( Example )
Type CodeableConcept
Summary true
Procedure.code
Element Id Procedure.code
Definition

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

Cardinality 0..1
Terminology Binding Procedure Codes (SNOMED CT) ( Example )
Type CodeableConcept
Requirements

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

Alternate Names type
Summary true
Procedure.subject
Element Id Procedure.subject
Definition

The person, animal On whom or group on which 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).

Cardinality 1..1
Type Reference ( Patient | Group | Device | Practitioner | Organization | Location )
Patterns Reference(Patient,Group,Device,Practitioner,Organization,Location): Common patterns = Participant
Alternate Names patient
Summary true
Procedure.encounter
Element Id Procedure.encounter
Definition

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

Cardinality 0..1
Type Reference ( Encounter )
Summary true
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.performed[x] Procedure.occurrence[x]
Element Id Procedure.performed[x] Procedure.occurrence[x]
Definition

Estimated or actual date, date-time, period, or age when the procedure was performed. 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.

Cardinality 0..1
Type dateTime | Period | string | Age | Range | Timing
[x] Note See Choice of Data Types for further information about how to use [x]
Summary true
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 Id Procedure.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).

Cardinality 0..1
Type dateTime
Summary true
Procedure.recorder
Element Id Procedure.recorder
Definition

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

Cardinality 0..1
Type Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole )
Patterns Reference(Patient,RelatedPerson,Practitioner,PractitionerRole): Common patterns = Participant
Summary true
Procedure.asserter Procedure.reported[x]
Element Id Procedure.asserter Procedure.reported[x]
Definition

Individual who is making 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 procedure statement. source of the report.

Cardinality 0..1
Type boolean | Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Organization )
Patterns Reference(Patient,RelatedPerson,Practitioner,PractitionerRole,Organization): Common patterns = Participant
[x] Note See Choice of Data Types 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 Names informer
Summary true
Procedure.performer
Element Id Procedure.performer
Definition

Limited to "real" people rather than equipment.

Cardinality 0..*
Summary true
Procedure.performer.function
Element Id Procedure.performer.function
Definition

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

Cardinality 0..1
Terminology Binding Procedure Performer Role Codes ( Example )
Type CodeableConcept
Requirements

Allows disambiguation of the types of involvement of different performers.

Summary true
Procedure.performer.actor
Element Id Procedure.performer.actor
Definition

The practitioner Indicates who was involved in or what performed the procedure.

Cardinality 1..1
Type Reference ( Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | CareTeam | HealthcareService )
Patterns Reference(Practitioner,PractitionerRole,Organization,Patient,RelatedPerson,Device,CareTeam,HealthcareService): Common patterns = Participant
Requirements

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

Summary true
Procedure.performer.onBehalfOf
Element Id Procedure.performer.onBehalfOf
Definition

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

Cardinality 0..1
Type Reference ( 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.

Procedure.location
Element Id Procedure.location
Definition

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

Cardinality 0..1
Type Reference ( Location )
Requirements

Ties a procedure to where the records are likely kept.

Summary true
Procedure.reasonCode Procedure.reason
Element Id Procedure.reasonCode Procedure.reason
Definition

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

Cardinality 0..*
Terminology Binding Procedure Reason Codes ( Example )
Type CodeableConcept Summary true Comments Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Procedure.reasonReference Element Id Procedure.reasonReference Definition The justification of why the procedure was performed. Cardinality 0..* Type Reference CodeableReference ( Condition | Observation | Procedure | DiagnosticReport | DocumentReference )
Patterns CodeableReference(Condition,Observation,Procedure,DiagnosticReport,DocumentReference): Common patterns = Event
Summary true
Comments

It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode Procedure.reason.concept when a code sufficiently describes the reason. Use Procedure.reasonReference Procedure.reason.reference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode Procedure.reason.concept and Procedure.reasonReference Procedure.reason.reference are not meant to be duplicative. For a single reason, either Procedure.reasonCode Procedure.reason.concept or Procedure.reasonReference Procedure.reason.reference can be used. Procedure.reasonCode Procedure.reason.concept may be a summary code, or Procedure.reasonReference Procedure.reason.reference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode Procedure.reason.concept and Procedure.reasonReference Procedure.reason.reference can be used if they are describing different reasons for the procedure.

Procedure.bodySite
Element Id Procedure.bodySite
Definition

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

Cardinality 0..*
Terminology Binding SNOMED CT Body Structures ( Example )
Type CodeableConcept
Summary true
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 Id Procedure.outcome
Definition

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

Cardinality 0..1
Terminology Binding Procedure Outcome Codes (SNOMED CT) ( Example )
Type CodeableConcept
Summary true
Comments

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

Procedure.report
Element Id Procedure.report
Definition

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

Cardinality 0..*
Type Reference ( DiagnosticReport | DocumentReference | Composition )
Patterns Reference(DiagnosticReport,DocumentReference,Composition): Common patterns = Event
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 Id Procedure.complication
Definition

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

Cardinality 0..*
Terminology Binding Condition/Problem/Diagnosis Codes ( Example )
Type CodeableConcept
Comments

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

Procedure.complicationDetail
Element Id Procedure.complicationDetail
Definition

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

Cardinality 0..*
Type Reference ( Condition )
Requirements

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

Procedure.followUp
Element Id Procedure.followUp
Definition

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

Cardinality 0..*
Terminology Binding Procedure Follow up Codes (SNOMED CT) ( Example )
Type CodeableConcept
Procedure.note
Element Id Procedure.note
Definition

Any other notes and comments about the procedure.

Cardinality 0..*
Type Annotation
Procedure.focalDevice
Element Id Procedure.focalDevice
Definition

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

Cardinality 0..*
Procedure.focalDevice.action
Element Id Procedure.focalDevice.action
Definition

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

Cardinality 0..1
Terminology Binding Procedure Device Action Codes ( Preferred )
Type CodeableConcept
Procedure.focalDevice.manipulated
Element Id Procedure.focalDevice.manipulated
Definition

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

Cardinality 1..1
Type Reference ( Device )
Procedure.usedReference Procedure.used
Element Id Procedure.usedReference Procedure.used
Definition

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

Cardinality 0..*
Terminology Binding FHIR Device Types ( Example )
Type Reference CodeableReference ( Device | Medication | Substance | BiologicallyDerivedProduct )
Patterns CodeableReference(Device,Medication,Substance,BiologicallyDerivedProduct): No common pattern
Requirements

Used for tracking contamination, etc.

Comments

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

Procedure.usedCode Procedure.supportingInfo
Element Id Procedure.usedCode Procedure.supportingInfo
Definition

Identifies coded items Other resources from the patient record that were used as part of 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.

Cardinality 0..*
Terminology Binding Type FHIR Device Types Reference ( Example Any )