DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

4.8.10.5.4 StructureDefinition: DAFProcedure

Definitions for the procedure-daf-dafprocedure Profile.

Procedure(DAFProcedure)
Definition

An action that is or was performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counseling or hypnotherapy.

Control1..1
TypeProcedure
Procedure.id
Definition

The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

Procedure.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Procedure.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

Procedure.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource

Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Procedure.text
Definition

A human-readable narrative that contains a summary of the resource, and may 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.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Procedure.contained
Definition

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.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Procedure.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order 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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.modifierExtension
Definition

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. Usually modifier elements provide negation or qualification. In order 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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.identifier
Definition

This records identifiers associated with this procedure that are defined by business processed and/ or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Control1..*
TypeIdentifier
Must Supporttrue
Requirements

Need to allow connection to a wider workflow.

Procedure.patient
Definition

The person on whom the procedure was performed.

Control1..1
TypeReference (U.S. Data Access Framework (DAF) Patient Profile))
Must Supporttrue
Procedure.status
Definition

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

Control1..1
BindingA code specifying the state of the procedure record
The codes SHALL be taken from ProcedureStatus
Typecode
Procedure.category
Definition

A code that classifies the procedure for searching, sorting and display purposes.

Control0..1
BindingA code that classifies a procedure for searching, sorting and display purposes
For example codes, see Procedure Category Codes (SNOMED CT)
TypeCodeableConcept
Procedure.type
Definition

SNOMED-CT | ICD-10 | CPT-4.

Control1..1
BindingCodes describing the Procedure Type
The codes SHALL be taken from DAFProcedureType; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Procedure.bodySite
Definition

Coded Responses fromBody Site Value Set.

Control0..*
BindingCodes describing anatomical locations
The codes SHALL be taken from SNOMED CT Body Structures; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Procedure.bodySite.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Procedure.bodySite.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.bodySite.modifierExtension
Definition

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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.bodySite.site[x]
Definition

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

Control1..1
TypeChoice of: CodeableConcept, Reference (BodySite))
Procedure.indication
Definition

The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.

Control0..*
TypeCodeableConcept
Comments

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapuetic.

Procedure.performer
Definition

Limited to 'real' people rather than equipment.

Control0..*
TypeElement
Must Supporttrue
Procedure.performer.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Procedure.performer.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.performer.modifierExtension
Definition

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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.performer.person
Definition

The practitioner who was involved in the procedure.

Control0..1
TypeReference (U.S. Data Access Framework (DAF) Practitioner Profile))
Must Supporttrue
Procedure.performer.role
Definition

E.g. surgeon, anaethetist, endoscopist.

Control0..1
TypeCodeableConcept
Procedure.performed[x]
Definition

The date(time)/period over which 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.

Control0..1
TypeChoice of: dateTime, Period
Must Supporttrue
Procedure.encounter
Definition

The encounter during which the procedure was performed.

Control0..1
TypeReference (U.S. Data Access Framework (DAF) Encounter profile))
Must Supporttrue
Procedure.location
Definition

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

Control0..1
TypeReference (Location))
Comments

Ties a procedure to where the records are kept.

Procedure.outcome
Definition

What was the outcome of the procedure - did it resolve reasons why the procedure was performed?

Control0..1
BindingThe outcome of a procedure - whether it resolveed the reasons why the procedure was performed
For example codes, see Procedure Outcome Codes (SNOMED CT)
TypeCodeableConcept
Procedure.report
Definition

This could be a histology result. There could potentially be multiple reports - e.g. if this was a procedure that made multiple biopsies.

Control0..*
TypeReference (DiagnosticReport))
Procedure.complication
Definition

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

Control0..*
TypeCodeableConcept
Procedure.followUp
Definition

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

Control0..*
BindingSpecific follow up required for a procedure e.g. removal of sutures
For example codes, see Procedure Follow up Codes (SNOMED CT)
TypeCodeableConcept
Procedure.relatedItem
Definition

Procedures may be related to other items such as procedures or medications. For example treating wound dehiscence following a previous procedure.

Control0..*
Typenull
Procedure.relatedItem.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Procedure.relatedItem.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.relatedItem.modifierExtension
Definition

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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.relatedItem.type
Definition

The nature of the relationship.

Control0..1
BindingThe nature of the relationship with this procedure
The codes SHALL be taken from ProcedureRelationshipType
Typecode
Procedure.relatedItem.target
Definition

The related item - e.g. a procedure.

Control0..1
TypeChoice of: Reference (AllergyIntolerance)), Reference (CarePlan)), Reference (Condition)), Reference (DiagnosticReport)), Reference (FamilyMemberHistory)), Reference (ImagingStudy)), Reference (Immunization)), Reference (ImmunizationRecommendation)), Reference (MedicationAdministration)), Reference (MedicationDispense)), Reference (MedicationPrescription)), Reference (MedicationStatement)), Reference (Observation)), Reference (Procedure))
Procedure.notes
Definition

Any other notes about the procedure - e.g. the operative notes.

Control0..1
Typestring
Procedure.device
Definition

A device change during the procedure.

Control0..*
Typenull
Procedure.device.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Procedure.device.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.device.modifierExtension
Definition

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 that contains it. Usually modifier elements provide negation or qualification. In order 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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.device.action
Definition

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

Control0..1
BindingThe kind of change that happened to the device during the procedure
The codes SHALL be taken from Procedure Device Action Codes
TypeCodeableConcept
Procedure.device.manipulated
Definition

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

Control1..1
TypeReference (Device))
Procedure.used
Definition

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

Control0..*
TypeChoice of: Reference (Device)), Reference (Medication)), Reference (Substance))
Requirements

Used for tracking contamination, etc.

Comments

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