STU 3 Candidate

This page is part of the FHIR Specification (v1.4.0: STU 3 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

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()
.