- An action that is being or was performed on a patient Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
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Key: = Must support, = QICore-defined extension, = Is-Modifier
Field Card. Type and Description 
approachBodySite 0..*List<BodySite>The approach body site used for this procedure. Multiple locations are allowed.bodySite 0..*List<Concept>Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.Binding: SNOMED CT Body Structures (Example)
category 0..1ConceptA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").Binding: Procedure Category Codes (SNOMED CT) (Example)
code 1..1ConceptThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").Binding: DAFProcedureType (Preferred)
complication 0..*List<Concept>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.Binding: Condition/Problem/Diagnosis Codes (Example)
encounter 0..1EncounterThe encounter during which the procedure was performed.focalDevice 0..*List<FocalDevice> (TBD)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.followUp 0..*List<Concept>If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.Binding: Procedure Follow up Codes (SNOMED CT) (Example)
identifier 0..*List<Identifier>This records identifiers associated with this procedure that are defined by business processes 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).incisionDateTime 0..1DateTimeThe time of the first incision.location 0..1LocationThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.notPerformed 0..1BooleanSet this to true if the record is saying that the procedure was NOT performed.notes 0..*List<Annotation>Any other notes about the procedure. E.g. the operative notes.outcome 0..1ConceptThe outcome of the procedure - did it resolve reasons for the procedure being performed?Binding: Procedure Outcome Codes (SNOMED CT) (Example)
performed[x] 0..1DateTime | interval<DateTime>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.performer 0..*List<Performer> (TBD)Limited to 'real' people rather than equipment.reasonNotPerformed 0..*List<Concept>A code indicating why the procedure was not performed.Binding: Procedure Not Performed Reason (SNOMED-CT) (Example)
reason[x] 0..1Concept | ConditionThe 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.Binding: Procedure Reason Codes (Example)
report 0..*List<DiagnosticReport>This could be a histology result, pathology report, surgical report, etc..request 0..1CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequestA reference to a resource that contains details of the request for this procedure.status 1..1codeA code specifying the state of the procedure. Generally this will be in-progress or completed state.Binding: ProcedureStatus (Required)
subject 1..1Patient | GroupThe person, animal or group on which the procedure was performed.used 0..*List<Device | Medication | Substance>Identifies medications, devices and any other substance used as part of the procedure.Key: = Must support, = QICore-defined extension, = Is-Modifier
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