Procedure
| Property | Value |
|---|---|
| Publisher | |
| Name | Procedure |
| URL | http://hl7.org/fhir/StructureDefinition/Procedure |
| Status | draft |
| Description | |
| Abstract | false |
Structure
| Path | Cardinality | Type | Description |
|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. |
| Procedure.id | 0..1 | http://hl7.org/fhirpath/System.String | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
| Procedure.meta | 0..1 | Meta | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. |
| Procedure.implicitRules | 0..1 | uri | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
| Procedure.language | 0..1 | code | The base language in which the resource is written. |
| Procedure.text | 0..1 | Narrative | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
| Procedure.contained | 0..* | Resource | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. |
| Procedure.extension | 0..* | Extension | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Procedure.modifierExtension | 0..* | Extension | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Procedure.identifier | 0..* | Identifier | 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. |
| Procedure.instantiatesCanonical | 0..* | canonical | 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. |
| Procedure.instantiatesUri | 0..* | uri | 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. |
| Procedure.basedOn | 0..* | Reference | A reference to a resource that contains details of the request for this procedure. |
| Procedure.partOf | 0..* | Reference | A larger event of which this particular procedure is a component or step. |
| Procedure.status | 1..1 | code | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. |
| Procedure.statusReason | 0..1 | CodeableConcept | Captures the reason for the current state of the procedure. |
| Procedure.category | 0..1 | CodeableConcept | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). |
| Procedure.code | 0..1 | CodeableConcept | The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). |
| Procedure.subject | 1..1 | Reference | The person, animal or group on which the procedure was performed. |
| Procedure.encounter | 0..1 | Reference | The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. |
| Procedure.performed[x] | 0..1 | dateTime | Estimated or actual date, date-time, period, or age when the procedure was performed. 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. |
| Procedure.recorder | 0..1 | Reference | Individual who recorded the record and takes responsibility for its content. |
| Procedure.asserter | 0..1 | Reference | Individual who is making the procedure statement. |
| Procedure.performer | 0..* | BackboneElement | Limited to "real" people rather than equipment. |
| Procedure.performer.id | 0..1 | http://hl7.org/fhirpath/System.String | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Procedure.performer.extension | 0..* | Extension | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Procedure.performer.modifierExtension | 0..* | Extension | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Procedure.performer.function | 0..1 | CodeableConcept | Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. |
| Procedure.performer.actor | 1..1 | Reference | The practitioner who was involved in the procedure. |
| Procedure.performer.onBehalfOf | 0..1 | Reference | The organization the device or practitioner was acting on behalf of. |
| Procedure.location | 0..1 | Reference | The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. |
| Procedure.reasonCode | 0..* | CodeableConcept | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. |
| Procedure.reasonReference | 0..* | Reference | The justification of why the procedure was performed. |
| Procedure.bodySite | 0..* | CodeableConcept | Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. |
| Procedure.outcome | 0..1 | CodeableConcept | The outcome of the procedure - did it resolve the reasons for the procedure being performed? |
| Procedure.report | 0..* | Reference | This could be a histology result, pathology report, surgical report, etc. |
| Procedure.complication | 0..* | CodeableConcept | 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. |
| Procedure.complicationDetail | 0..* | Reference | Any complications that occurred during the procedure, or in the immediate post-performance period. |
| Procedure.followUp | 0..* | CodeableConcept | 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. |
| Procedure.note | 0..* | Annotation | Any other notes and comments about the procedure. |
| Procedure.focalDevice | 0..* | BackboneElement | 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. |
| Procedure.focalDevice.id | 0..1 | http://hl7.org/fhirpath/System.String | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Procedure.focalDevice.extension | 0..* | Extension | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Procedure.focalDevice.modifierExtension | 0..* | Extension | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Procedure.focalDevice.action | 0..1 | CodeableConcept | The kind of change that happened to the device during the procedure. |
| Procedure.focalDevice.manipulated | 1..1 | Reference | The device that was manipulated (changed) during the procedure. |
| Procedure.usedReference | 0..* | Reference | Identifies medications, devices and any other substance used as part of the procedure. |
| Procedure.usedCode | 0..* | CodeableConcept | Identifies coded items that were used as part of the procedure. |
Search Parameters
| Name | Type | Description | Expression |
|---|---|---|---|
| _text | string | Search on the narrative of the resource | |
| _content | string | Search on the entire content of the resource | |
| _filter | token | Filter search parameter which supports a more sophisticated grammar for searching. See documentation for further details | |
| _has | string | Provides limited support for reverse chaining - that is, selecting resources based on the properties of resources that refer to them (instead of chaining where resources can be selected based on the properties of resources that they refer to). See the FHIR search page for further documentation | |
| _id | token | Logical id of this artifact | Resource.id |
| _lastUpdated | date | When the resource version last changed | Resource.meta.lastUpdated |
| _list | string | All resources in nominated list (by id, Type/id, url or one of the magic List types) | |
| _profile | uri | Profiles this resource claims to conform to | Resource.meta.profile |
| _query | token | A custom search profile that describes a specific defined query operation | |
| _security | token | Security Labels applied to this resource | Resource.meta.security |
| _source | uri | Identifies where the resource comes from | Resource.meta.source |
| _tag | token | Tags applied to this resource | Resource.meta.tag |
| _text | string | Search on the narrative text (html) of the resource | |
| _type | token | Used when a search is performed in a context which doesn't limit the search to indicate which types are being searched. See the FHIR search page for further discussion | |
| code | token | Multiple Resources: * AllergyIntolerance: Code that identifies the allergy or intolerance* Condition: Code for the condition* DeviceRequest: Code for what is being requested/ordered* DiagnosticReport: The code for the report, as opposed to codes for the atomic results, which are the names on the observation resource referred to from the result* FamilyMemberHistory: A search by a condition code* List: What the purpose of this list is* Medication: Returns medications for a specific code* MedicationAdministration: Return administrations of this medication code* MedicationDispense: Returns dispenses of this medicine code* MedicationRequest: Return prescriptions of this medication code* MedicationStatement: Return statements of this medication code* Observation: The code of the observation type* Procedure: A code to identify a procedure* ServiceRequest: What is being requested/ordered | AllergyIntolerance.code / AllergyIntolerance.reaction.substance / Condition.code / (DeviceRequest.code.ofType(CodeableConcept)) / DiagnosticReport.code / FamilyMemberHistory.condition.code / List.code / Medication.code / (MedicationAdministration.medication.ofType(CodeableConcept)) / (MedicationDispense.medication.ofType(CodeableConcept)) / (MedicationRequest.medication.ofType(CodeableConcept)) / (MedicationStatement.medication.ofType(CodeableConcept)) / Observation.code / Procedure.code / ServiceRequest.code |
| date | date | Multiple Resources: * AllergyIntolerance: Date first version of the resource instance was recorded* CarePlan: Time period plan covers* CareTeam: Time period team covers* ClinicalImpression: When the assessment was documented* Composition: Composition editing time* Consent: When this Consent was created or indexed* DiagnosticReport: The clinically relevant time of the report* Encounter: A date within the period the Encounter lasted* EpisodeOfCare: The provided date search value falls within the episode of care's period* FamilyMemberHistory: When history was recorded or last updated* Flag: Time period when flag is active* Immunization: Vaccination (non)-Administration Date* List: When the list was prepared* Observation: Obtained date/time. If the obtained element is a period, a date that falls in the period* Procedure: When the procedure was performed* RiskAssessment: When was assessment made?* SupplyRequest: When the request was made | AllergyIntolerance.recordedDate / CarePlan.period / CareTeam.period / ClinicalImpression.date / Composition.date / Consent.dateTime / DiagnosticReport.effective / Encounter.period / EpisodeOfCare.period / FamilyMemberHistory.date / Flag.period / (Immunization.occurrence.ofType(dateTime)) / List.date / Observation.effective / Procedure.performed / (RiskAssessment.occurrence.ofType(dateTime)) / SupplyRequest.authoredOn |
| identifier | token | Multiple Resources: * AllergyIntolerance: External ids for this item* CarePlan: External Ids for this plan* CareTeam: External Ids for this team* Composition: Version-independent identifier for the Composition* Condition: A unique identifier of the condition record* Consent: Identifier for this record (external references)* DetectedIssue: Unique id for the detected issue* DeviceRequest: Business identifier for request/order* DiagnosticReport: An identifier for the report* DocumentManifest: Unique Identifier for the set of documents* DocumentReference: Master Version Specific Identifier* Encounter: Identifier(s) by which this encounter is known* EpisodeOfCare: Business Identifier(s) relevant for this EpisodeOfCare* FamilyMemberHistory: A search by a record identifier* Goal: External Ids for this goal* ImagingStudy: Identifiers for the Study, such as DICOM Study Instance UID and Accession number* Immunization: Business identifier* List: Business identifier* MedicationAdministration: Return administrations with this external identifier* MedicationDispense: Returns dispenses with this external identifier* MedicationRequest: Return prescriptions with this external identifier* MedicationStatement: Return statements with this external identifier* NutritionOrder: Return nutrition orders with this external identifier* Observation: The unique id for a particular observation* Procedure: A unique identifier for a procedure* RiskAssessment: Unique identifier for the assessment* ServiceRequest: Identifiers assigned to this order* SupplyDelivery: External identifier* SupplyRequest: Business Identifier for SupplyRequest* VisionPrescription: Return prescriptions with this external identifier | AllergyIntolerance.identifier / CarePlan.identifier / CareTeam.identifier / Composition.identifier / Condition.identifier / Consent.identifier / DetectedIssue.identifier / DeviceRequest.identifier / DiagnosticReport.identifier / DocumentManifest.masterIdentifier / DocumentManifest.identifier / DocumentReference.masterIdentifier / DocumentReference.identifier / Encounter.identifier / EpisodeOfCare.identifier / FamilyMemberHistory.identifier / Goal.identifier / ImagingStudy.identifier / Immunization.identifier / List.identifier / MedicationAdministration.identifier / MedicationDispense.identifier / MedicationRequest.identifier / MedicationStatement.identifier / NutritionOrder.identifier / Observation.identifier / Procedure.identifier / RiskAssessment.identifier / ServiceRequest.identifier / SupplyDelivery.identifier / SupplyRequest.identifier / VisionPrescription.identifier |
| patient | reference | Multiple Resources: * AllergyIntolerance: Who the sensitivity is for* CarePlan: Who the care plan is for* CareTeam: Who care team is for* ClinicalImpression: Patient or group assessed* Composition: Who and/or what the composition is about* Condition: Who has the condition?* Consent: Who the consent applies to* DetectedIssue: Associated patient* DeviceRequest: Individual the service is ordered for* DeviceUseStatement: Search by subject - a patient* DiagnosticReport: The subject of the report if a patient* DocumentManifest: The subject of the set of documents* DocumentReference: Who/what is the subject of the document* Encounter: The patient or group present at the encounter* EpisodeOfCare: The patient who is the focus of this episode of care* FamilyMemberHistory: The identity of a subject to list family member history items for* Flag: The identity of a subject to list flags for* Goal: Who this goal is intended for* ImagingStudy: Who the study is about* Immunization: The patient for the vaccination record* List: If all resources have the same subject* MedicationAdministration: The identity of a patient to list administrations for* MedicationDispense: The identity of a patient to list dispenses for* MedicationRequest: Returns prescriptions for a specific patient* MedicationStatement: Returns statements for a specific patient.* NutritionOrder: The identity of the person who requires the diet, formula or nutritional supplement* Observation: The subject that the observation is about (if patient)* Procedure: Search by subject - a patient* RiskAssessment: Who/what does assessment apply to?* ServiceRequest: Search by subject - a patient* SupplyDelivery: Patient for whom the item is supplied* VisionPrescription: The identity of a patient to list dispenses for | AllergyIntolerance.patient / CarePlan.subject.where(resolve() is Patient) / CareTeam.subject.where(resolve() is Patient) / ClinicalImpression.subject.where(resolve() is Patient) / Composition.subject.where(resolve() is Patient) / Condition.subject.where(resolve() is Patient) / Consent.patient / DetectedIssue.patient / DeviceRequest.subject.where(resolve() is Patient) / DeviceUseStatement.subject.where(resolve() is Patient) / DiagnosticReport.subject.where(resolve() is Patient) / DocumentManifest.subject.where(resolve() is Patient) / DocumentReference.subject.where(resolve() is Patient) / Encounter.subject.where(resolve() is Patient) / EpisodeOfCare.patient / FamilyMemberHistory.patient / Flag.subject.where(resolve() is Patient) / Goal.subject.where(resolve() is Patient) / ImagingStudy.subject.where(resolve() is Patient) / Immunization.patient / List.subject.where(resolve() is Patient) / MedicationAdministration.subject.where(resolve() is Patient) / MedicationDispense.subject.where(resolve() is Patient) / MedicationRequest.subject.where(resolve() is Patient) / MedicationStatement.subject.where(resolve() is Patient) / NutritionOrder.patient / Observation.subject.where(resolve() is Patient) / Procedure.subject.where(resolve() is Patient) / RiskAssessment.subject.where(resolve() is Patient) / ServiceRequest.subject.where(resolve() is Patient) / SupplyDelivery.patient / VisionPrescription.patient |
| encounter | reference | Multiple Resources: * Composition: Context of the Composition* DeviceRequest: Encounter during which request was created* DiagnosticReport: The Encounter when the order was made* DocumentReference: Context of the document content* Flag: Alert relevant during encounter* List: Context in which list created* NutritionOrder: Return nutrition orders with this encounter identifier* Observation: Encounter related to the observation* Procedure: Encounter created as part of* RiskAssessment: Where was assessment performed?* ServiceRequest: An encounter in which this request is made* VisionPrescription: Return prescriptions with this encounter identifier | Composition.encounter / DeviceRequest.encounter / DiagnosticReport.encounter / DocumentReference.context.encounter.where(resolve() is Encounter) / Flag.encounter / List.encounter / NutritionOrder.encounter / Observation.encounter / Procedure.encounter / RiskAssessment.encounter / ServiceRequest.encounter / VisionPrescription.encounter |
| based-on | reference | A request for this procedure | Procedure.basedOn |
| category | token | Classification of the procedure | Procedure.category |
| instantiates-canonical | reference | Instantiates FHIR protocol or definition | Procedure.instantiatesCanonical |
| instantiates-uri | uri | Instantiates external protocol or definition | Procedure.instantiatesUri |
| location | reference | Where the procedure happened | Procedure.location |
| part-of | reference | Part of referenced event | Procedure.partOf |
| performer | reference | The reference to the practitioner | Procedure.performer.actor |
| reason-code | token | Coded reason procedure performed | Procedure.reasonCode |
| reason-reference | reference | The justification that the procedure was performed | Procedure.reasonReference |
| status | token | preparation / in-progress / not-done / on-hold / stopped / completed / entered-in-error / unknown | Procedure.status |
| subject | reference | Search by subject | Procedure.subject |