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 . Page versions: R5 R4B R4 R3 R2
This resource maintained by the Patient Care Work Group
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.
This resource is used to record the details of procedures performed on a patient. A procedure is an activity that is performed with or on a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counselling, physiotherapy, exercise, etc. Procedures may be performed by a healthcare professional, a friend or relative or in some cases by the patient themselves.
This resource provides summary information about the occurrence of the procedure and is not intended to provide real-time snapshots of a procedure as it unfolds, though for long-running procedures such as psychotherapy, it could represent summary level information about overall progres. The creation of a resource to support detailed real-time procedure information awaits the identification of a specific implementation use-case to share such information.
Procedures do not include actions things for which there are specific resources, such as immunizations, drug administrations and communications. The boundary between determining whether an action is considered to be training or counselling (and thus a procedure) as opposed to a Communication is based on whether there's a specific intent to change the mind-set of the patient. Mere disclosure of information would be considered a Communication. A process that involves verification of the patient's comprehension or to change the patient's mental state would be a Procedure.
Note that many diagnostic processes are procedures that generate Observations and DiagnosticReports. In many cases, such an observation does not require an explicit representation of the procedure used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the procedure resource is used to describe the activity.
This resource is referenced by ClinicalImpression and Condition
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | DomainResource | An action that was or is currently being performed on a patient | ||
identifier | Σ | 0..* | Identifier | External Ids for this procedure |
patient | Σ | 1..1 | Patient | Who procedure was performed on |
status | Σ | 1..1 | code | in-progress | aborted | completed | entered-in-error ProcedureStatus (Required) |
category | Σ | 0..1 | CodeableConcept | Classification of the procedure ProcedureCategory (Example) |
type | Σ | 1..1 | CodeableConcept | Identification of the procedure ProcedureType (Example) |
bodySite | Σ | 0..* | Element | Precise location details |
site[x] | Σ | Precise location details | ||
siteCodeableConcept | 1..1 | CodeableConcept | ||
siteReference | 1..1 | BodySite | ||
indication | Σ | 0..* | CodeableConcept | Reason procedure performed |
performer | Σ | 0..* | Element | The people who performed the procedure |
person | Σ | 0..1 | Practitioner | Patient | RelatedPerson | The reference to the practitioner |
role | Σ | 0..1 | CodeableConcept | The role the person was in |
performed[x] | Σ | Date/Period the procedure was performed | ||
performedDateTime | 0..1 | dateTime | ||
performedPeriod | 0..1 | Period | ||
encounter | Σ | 0..1 | Encounter | The encounter when procedure performed |
location | Σ | 0..1 | Location | Where the procedure happened |
outcome | Σ | 0..1 | CodeableConcept | What was result of procedure? ProcedureOutcome (Example) |
report | 0..* | DiagnosticReport | Any report that results from the procedure | |
complication | 0..* | CodeableConcept | Complication following the procedure | |
followUp | 0..* | CodeableConcept | Instructions for follow up ProcedureFollowUp (Example) | |
relatedItem | 0..* | Element | A procedure that is related to this one | |
type | 0..1 | code | caused-by | because-of ProcedureRelationshipType (Required) | |
target | 0..1 | AllergyIntolerance | CarePlan | Condition | DiagnosticReport | FamilyMemberHistory | ImagingStudy | Immunization | ImmunizationRecommendation | MedicationAdministration | MedicationDispense | MedicationPrescription | MedicationStatement | Observation | Procedure | The related item - e.g. a procedure | |
notes | 0..1 | string | Additional information about procedure | |
device | 0..* | Element | Device changed in procedure | |
action | 0..1 | CodeableConcept | Kind of change to device DeviceActionKind (Required) | |
manipulated | 1..1 | Device | Device that was changed | |
used | 0..* | Device | Medication | Substance | Items used during procedure |
UML Diagram
XML Template
<Procedure xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier External Ids for this procedure --></identifier> <patient><!-- 1..1 Reference(Patient) Who procedure was performed on --></patient> <status value="[code]"/><!-- 1..1 in-progress | aborted | completed | entered-in-error --> <category><!-- 0..1 CodeableConcept Classification of the procedure --></category> <type><!-- 1..1 CodeableConcept Identification of the procedure --></type> <bodySite> <!-- 0..* Precise location details --> <site[x]><!-- 1..1 CodeableConcept|Reference(BodySite) Precise location details --></site[x]> </bodySite> <indication><!-- 0..* CodeableConcept Reason procedure performed --></indication> <performer> <!-- 0..* The people who performed the procedure --> <person><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) The reference to the practitioner --></person> <role><!-- 0..1 CodeableConcept The role the person was in --></role> </performer> <performed[x]><!-- 0..1 dateTime|Period Date/Period the procedure was performed --></performed[x]> <encounter><!-- 0..1 Reference(Encounter) The encounter when procedure performed --></encounter> <location><!-- 0..1 Reference(Location) Where the procedure happened --></location> <outcome><!-- 0..1 CodeableConcept What was result of procedure? --></outcome> <report><!-- 0..* Reference(DiagnosticReport) Any report that results from the procedure --></report> <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication> <followUp><!-- 0..* CodeableConcept Instructions for follow up --></followUp> <relatedItem> <!-- 0..* A procedure that is related to this one --> <type value="[code]"/><!-- 0..1 caused-by | because-of --> <target><!-- 0..1 Reference(AllergyIntolerance|CarePlan|Condition| DiagnosticReport|FamilyMemberHistory|ImagingStudy|Immunization| ImmunizationRecommendation|MedicationAdministration|MedicationDispense| MedicationPrescription|MedicationStatement|Observation|Procedure) The related item - e.g. a procedure --></target> </relatedItem> <notes value="[string]"/><!-- 0..1 Additional information about procedure --> <device> <!-- 0..* Device changed in procedure --> <action><!-- 0..1 CodeableConcept Kind of change to device --></action> <manipulated><!-- 1..1 Reference(Device) Device that was changed --></manipulated> </device> <used><!-- 0..* Reference(Device|Medication|Substance) Items used during procedure --></used> </Procedure>
JSON Template
{ "resourceType" : "Procedure", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // External Ids for this procedure "patient" : { Reference(Patient) }, // R! Who procedure was performed on "status" : "<code>", // R! in-progress | aborted | completed | entered-in-error "category" : { CodeableConcept }, // Classification of the procedure "type" : { CodeableConcept }, // R! Identification of the procedure "bodySite" : [{ // Precise location details // site[x]: Precise location details. One of these 2: "siteCodeableConcept" : { CodeableConcept } "siteReference" : { Reference(BodySite) } }], "indication" : [{ CodeableConcept }], // Reason procedure performed "performer" : [{ // The people who performed the procedure "person" : { Reference(Practitioner|Patient|RelatedPerson) }, // The reference to the practitioner "role" : { CodeableConcept } // The role the person was in }], // performed[x]: Date/Period the procedure was performed. One of these 2: "performedDateTime" : "<dateTime>", "performedPeriod" : { Period }, "encounter" : { Reference(Encounter) }, // The encounter when procedure performed "location" : { Reference(Location) }, // Where the procedure happened "outcome" : { CodeableConcept }, // What was result of procedure? "report" : [{ Reference(DiagnosticReport) }], // Any report that results from the procedure "complication" : [{ CodeableConcept }], // Complication following the procedure "followUp" : [{ CodeableConcept }], // Instructions for follow up "relatedItem" : [{ // A procedure that is related to this one "type" : "<code>", // caused-by | because-of "target" : { Reference(AllergyIntolerance|CarePlan|Condition| DiagnosticReport|FamilyMemberHistory|ImagingStudy|Immunization| ImmunizationRecommendation|MedicationAdministration|MedicationDispense| MedicationPrescription|MedicationStatement|Observation|Procedure) } // The related item - e.g. a procedure }], "notes" : "<string>", // Additional information about procedure "device" : [{ // Device changed in procedure "action" : { CodeableConcept }, // Kind of change to device "manipulated" : { Reference(Device) } // R! Device that was changed }], "used" : [{ Reference(Device|Medication|Substance) }] // Items used during procedure }
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | DomainResource | An action that was or is currently being performed on a patient | ||
identifier | Σ | 0..* | Identifier | External Ids for this procedure |
patient | Σ | 1..1 | Patient | Who procedure was performed on |
status | Σ | 1..1 | code | in-progress | aborted | completed | entered-in-error ProcedureStatus (Required) |
category | Σ | 0..1 | CodeableConcept | Classification of the procedure ProcedureCategory (Example) |
type | Σ | 1..1 | CodeableConcept | Identification of the procedure ProcedureType (Example) |
bodySite | Σ | 0..* | Element | Precise location details |
site[x] | Σ | Precise location details | ||
siteCodeableConcept | 1..1 | CodeableConcept | ||
siteReference | 1..1 | BodySite | ||
indication | Σ | 0..* | CodeableConcept | Reason procedure performed |
performer | Σ | 0..* | Element | The people who performed the procedure |
person | Σ | 0..1 | Practitioner | Patient | RelatedPerson | The reference to the practitioner |
role | Σ | 0..1 | CodeableConcept | The role the person was in |
performed[x] | Σ | Date/Period the procedure was performed | ||
performedDateTime | 0..1 | dateTime | ||
performedPeriod | 0..1 | Period | ||
encounter | Σ | 0..1 | Encounter | The encounter when procedure performed |
location | Σ | 0..1 | Location | Where the procedure happened |
outcome | Σ | 0..1 | CodeableConcept | What was result of procedure? ProcedureOutcome (Example) |
report | 0..* | DiagnosticReport | Any report that results from the procedure | |
complication | 0..* | CodeableConcept | Complication following the procedure | |
followUp | 0..* | CodeableConcept | Instructions for follow up ProcedureFollowUp (Example) | |
relatedItem | 0..* | Element | A procedure that is related to this one | |
type | 0..1 | code | caused-by | because-of ProcedureRelationshipType (Required) | |
target | 0..1 | AllergyIntolerance | CarePlan | Condition | DiagnosticReport | FamilyMemberHistory | ImagingStudy | Immunization | ImmunizationRecommendation | MedicationAdministration | MedicationDispense | MedicationPrescription | MedicationStatement | Observation | Procedure | The related item - e.g. a procedure | |
notes | 0..1 | string | Additional information about procedure | |
device | 0..* | Element | Device changed in procedure | |
action | 0..1 | CodeableConcept | Kind of change to device DeviceActionKind (Required) | |
manipulated | 1..1 | Device | Device that was changed | |
used | 0..* | Device | Medication | Substance | Items used during procedure |
XML Template
<Procedure xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier External Ids for this procedure --></identifier> <patient><!-- 1..1 Reference(Patient) Who procedure was performed on --></patient> <status value="[code]"/><!-- 1..1 in-progress | aborted | completed | entered-in-error --> <category><!-- 0..1 CodeableConcept Classification of the procedure --></category> <type><!-- 1..1 CodeableConcept Identification of the procedure --></type> <bodySite> <!-- 0..* Precise location details --> <site[x]><!-- 1..1 CodeableConcept|Reference(BodySite) Precise location details --></site[x]> </bodySite> <indication><!-- 0..* CodeableConcept Reason procedure performed --></indication> <performer> <!-- 0..* The people who performed the procedure --> <person><!-- 0..1 Reference(Practitioner|Patient|RelatedPerson) The reference to the practitioner --></person> <role><!-- 0..1 CodeableConcept The role the person was in --></role> </performer> <performed[x]><!-- 0..1 dateTime|Period Date/Period the procedure was performed --></performed[x]> <encounter><!-- 0..1 Reference(Encounter) The encounter when procedure performed --></encounter> <location><!-- 0..1 Reference(Location) Where the procedure happened --></location> <outcome><!-- 0..1 CodeableConcept What was result of procedure? --></outcome> <report><!-- 0..* Reference(DiagnosticReport) Any report that results from the procedure --></report> <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication> <followUp><!-- 0..* CodeableConcept Instructions for follow up --></followUp> <relatedItem> <!-- 0..* A procedure that is related to this one --> <type value="[code]"/><!-- 0..1 caused-by | because-of --> <target><!-- 0..1 Reference(AllergyIntolerance|CarePlan|Condition| DiagnosticReport|FamilyMemberHistory|ImagingStudy|Immunization| ImmunizationRecommendation|MedicationAdministration|MedicationDispense| MedicationPrescription|MedicationStatement|Observation|Procedure) The related item - e.g. a procedure --></target> </relatedItem> <notes value="[string]"/><!-- 0..1 Additional information about procedure --> <device> <!-- 0..* Device changed in procedure --> <action><!-- 0..1 CodeableConcept Kind of change to device --></action> <manipulated><!-- 1..1 Reference(Device) Device that was changed --></manipulated> </device> <used><!-- 0..* Reference(Device|Medication|Substance) Items used during procedure --></used> </Procedure>
JSON Template
{ "resourceType" : "Procedure", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // External Ids for this procedure "patient" : { Reference(Patient) }, // R! Who procedure was performed on "status" : "<code>", // R! in-progress | aborted | completed | entered-in-error "category" : { CodeableConcept }, // Classification of the procedure "type" : { CodeableConcept }, // R! Identification of the procedure "bodySite" : [{ // Precise location details // site[x]: Precise location details. One of these 2: "siteCodeableConcept" : { CodeableConcept } "siteReference" : { Reference(BodySite) } }], "indication" : [{ CodeableConcept }], // Reason procedure performed "performer" : [{ // The people who performed the procedure "person" : { Reference(Practitioner|Patient|RelatedPerson) }, // The reference to the practitioner "role" : { CodeableConcept } // The role the person was in }], // performed[x]: Date/Period the procedure was performed. One of these 2: "performedDateTime" : "<dateTime>", "performedPeriod" : { Period }, "encounter" : { Reference(Encounter) }, // The encounter when procedure performed "location" : { Reference(Location) }, // Where the procedure happened "outcome" : { CodeableConcept }, // What was result of procedure? "report" : [{ Reference(DiagnosticReport) }], // Any report that results from the procedure "complication" : [{ CodeableConcept }], // Complication following the procedure "followUp" : [{ CodeableConcept }], // Instructions for follow up "relatedItem" : [{ // A procedure that is related to this one "type" : "<code>", // caused-by | because-of "target" : { Reference(AllergyIntolerance|CarePlan|Condition| DiagnosticReport|FamilyMemberHistory|ImagingStudy|Immunization| ImmunizationRecommendation|MedicationAdministration|MedicationDispense| MedicationPrescription|MedicationStatement|Observation|Procedure) } // The related item - e.g. a procedure }], "notes" : "<string>", // Additional information about procedure "device" : [{ // Device changed in procedure "action" : { CodeableConcept }, // Kind of change to device "manipulated" : { Reference(Device) } // R! Device that was changed }], "used" : [{ Reference(Device|Medication|Substance) }] // Items used during procedure }
Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON)
Path | Definition | Type | Reference |
---|---|---|---|
Procedure.status | A code specifying the state of the procedure record | Required | http://hl7.org/fhir/procedure-status |
Procedure.category | A code that classifies a procedure for searching, sorting and display purposes | Example | http://hl7.org/fhir/vs/procedure-category |
Procedure.type | A code for a type of procedure | Example | http://hl7.org/fhir/vs/procedure-type |
Procedure.outcome | The outcome of a procedure - whether it resolveed the reasons why the procedure was performed | Example | http://hl7.org/fhir/vs/procedure-outcome |
Procedure.followUp | Specific follow up required for a procedure e.g. removal of sutures | Example | http://hl7.org/fhir/vs/procedure-followup |
Procedure.relatedItem.type | The nature of the relationship with this procedure | Required | http://hl7.org/fhir/procedure-relationship-type |
Procedure.device.action | The kind of change that happened to the device during the procedure | Required | http://hl7.org/fhir/vs/device-action |
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Paths |
date | date | Date/Period the procedure was performed | Procedure.performed[x] |
encounter | reference | The encounter when procedure performed | Procedure.encounter (Encounter) |
location | reference | Where the procedure happened | Procedure.location (Location) |
patient | reference | The identity of a patient to list procedures for | Procedure.patient (Patient) |
performer | reference | The reference to the practitioner | Procedure.performer.person (Patient, Practitioner, RelatedPerson) |
type | token | Type of procedure | Procedure.type |