GAO Ballot Package

This page is part of the FHIR Specification (v1.1.0: STU 3 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

This is a frozen snapshot of the FHIR specification created for the purpose of balloting the GAO implementation Guide. It includes draft changes that may be part of the future DSTU 2.1 release but further change is expected. Readers should focus solely on the GAO implementation content, and FHIR DSTU 2 for other purposes.

F.30.1 StructureDefinition: QICore-Procedure

The official URL for this profile is: 

http://hl7.org/fhir/StructureDefinition/qicore-procedure

Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

This profile was published on Fri, Feb 27, 2015 00:00+1100 as a draft by Health Level Seven International (Clinical Quality Information - QICore).

F.30.1.1 Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*ProcedureAn action that is being or was performed on a patient
pro-1: Reason not performed is only permitted if notPerformed indicator is true
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?! ∑0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: IETF BCP-47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... procedure-approachBodySite 0..*Reference(BodySite)Extension
URL: http://hl7.org/fhir/StructureDefinition/procedure-approachBodySite
... procedure-incisionDateTime 0..1dateTimeExtension
URL: http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑0..*IdentifierExternal Identifiers for this procedure
... subject S ∑1..1Reference(QICore-Patient | Group)Who the procedure was performed on
... status ?! S∑1..1codein-progress | aborted | completed | entered-in-error
Binding: ProcedureStatus (required)
... category ∑0..1CodeableConceptClassification of the procedure
Binding: Procedure Category Codes (SNOMED CT) (example)
... code S ∑1..1CodeableConceptIdentification of the procedure
Binding: DAFProcedureType (preferred)
... notPerformed ?!0..1booleanTrue if procedure was not performed as scheduled
... reasonNotPerformed I0..*CodeableConceptReason procedure was not performed
Binding: Procedure Not Performed Reason (SNOMED-CT) (example)
... bodySite S ∑0..*CodeableConceptTarget body sites
Binding: SNOMED CT Body Structures (example)
... reason[x] S ∑0..1CodeableConcept, Reference(Condition)Reason procedure performed
Binding: Procedure Reason Codes (example)
... performer S ∑0..*BackboneElementThe people who performed the procedure
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... actor ∑0..1Reference(QICore-Practitioner | QICore-Organization | QICore-Patient | QICore-RelatedPerson)The reference to the practitioner
.... role ∑0..1CodeableConceptThe role the actor was in
Binding: Procedure Performer Role Codes (example)
... performed[x] S ∑0..1dateTime, PeriodDate/Period the procedure was performed
... encounter S ∑0..1Reference(QICore-Encounter)The encounter associated with the procedure
... location ∑0..1Reference(QICore-Location)Where the procedure happened
... outcome ∑0..1CodeableConceptThe result of procedure
Binding: Procedure Outcome Codes (SNOMED CT) (example)
... report S0..*Reference(QICore-DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/Diagnosis Codes (example)
... followUp 0..*CodeableConceptInstructions for follow up
Binding: Procedure Follow up Codes (SNOMED CT) (example)
... request 0..1Reference(CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequest)A request for this procedure
... notes 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementDevice changed in procedure
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... action 0..1CodeableConceptKind of change to device
Binding: Procedure Device Action Codes (required)
.... manipulated 1..1Reference(QICore-Device)Device that was changed
... used 0..*Reference(Device | Medication | Substance)Items used during procedure

doco Documentation for this format

todo

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*ProcedureAn action that is being or was performed on a patient
pro-1: Reason not performed is only permitted if notPerformed indicator is true
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?! ∑0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: IETF BCP-47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... procedure-approachBodySite 0..*Reference(BodySite)Extension
URL: http://hl7.org/fhir/StructureDefinition/procedure-approachBodySite
... procedure-incisionDateTime 0..1dateTimeExtension
URL: http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑0..*IdentifierExternal Identifiers for this procedure
... subject S ∑1..1Reference(QICore-Patient | Group)Who the procedure was performed on
... status ?! S∑1..1codein-progress | aborted | completed | entered-in-error
Binding: ProcedureStatus (required)
... category ∑0..1CodeableConceptClassification of the procedure
Binding: Procedure Category Codes (SNOMED CT) (example)
... code S ∑1..1CodeableConceptIdentification of the procedure
Binding: DAFProcedureType (preferred)
... notPerformed ?!0..1booleanTrue if procedure was not performed as scheduled
... reasonNotPerformed I0..*CodeableConceptReason procedure was not performed
Binding: Procedure Not Performed Reason (SNOMED-CT) (example)
... bodySite S ∑0..*CodeableConceptTarget body sites
Binding: SNOMED CT Body Structures (example)
... reason[x] S ∑0..1CodeableConcept, Reference(Condition)Reason procedure performed
Binding: Procedure Reason Codes (example)
... performer S ∑0..*BackboneElementThe people who performed the procedure
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... actor ∑0..1Reference(QICore-Practitioner | QICore-Organization | QICore-Patient | QICore-RelatedPerson)The reference to the practitioner
.... role ∑0..1CodeableConceptThe role the actor was in
Binding: Procedure Performer Role Codes (example)
... performed[x] S ∑0..1dateTime, PeriodDate/Period the procedure was performed
... encounter S ∑0..1Reference(QICore-Encounter)The encounter associated with the procedure
... location ∑0..1Reference(QICore-Location)Where the procedure happened
... outcome ∑0..1CodeableConceptThe result of procedure
Binding: Procedure Outcome Codes (SNOMED CT) (example)
... report S0..*Reference(QICore-DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/Diagnosis Codes (example)
... followUp 0..*CodeableConceptInstructions for follow up
Binding: Procedure Follow up Codes (SNOMED CT) (example)
... request 0..1Reference(CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequest)A request for this procedure
... notes 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementDevice changed in procedure
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... action 0..1CodeableConceptKind of change to device
Binding: Procedure Device Action Codes (required)
.... manipulated 1..1Reference(QICore-Device)Device that was changed
... used 0..*Reference(Device | Medication | Substance)Items used during procedure

doco Documentation for this format

XML Template

JSON Template

todo

 

Other representations of profile: Schematron

F.30.1.2 Terminology Bindings

PathNameConformanceValueSet
Procedure.language?extrequiredhttp://tools.ietf.org/html/bcp47
Procedure.statusProcedureStatusrequiredProcedureStatus
Procedure.categoryProcedure Category Codes (SNOMED CT)exampleProcedure Category Codes (SNOMED CT)
Procedure.codeDAFProcedureTypepreferredDAFProcedureType
Procedure.reasonNotPerformedProcedure Not Performed Reason (SNOMED-CT)exampleProcedure Not Performed Reason (SNOMED-CT)
Procedure.bodySiteSNOMED CT Body StructuresexampleSNOMED CT Body Structures
Procedure.reason[x]Procedure Reason CodesexampleProcedure Reason Codes
Procedure.performer.roleProcedure Performer Role CodesexampleProcedure Performer Role Codes
Procedure.outcomeProcedure Outcome Codes (SNOMED CT)exampleProcedure Outcome Codes (SNOMED CT)
Procedure.complicationCondition/Problem/Diagnosis CodesexampleCondition/Problem/Diagnosis Codes
Procedure.followUpProcedure Follow up Codes (SNOMED CT)exampleProcedure Follow up Codes (SNOMED CT)
Procedure.focalDevice.actionProcedure Device Action CodesrequiredProcedure Device Action Codes

F.30.1.3 Constraints

IdPathDetailsRequirements
pro-1ProcedureReason not performed is only permitted if notPerformed indicator is true
XPath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true()
.