STU 3 Ballot

This page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). 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

9.8 Resource Procedure - Content

Patient Care Work GroupMaturity Level: 1Compartments: Encounter, Patient, Practitioner, RelatedPerson

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

9.8.1 Scope and Usage

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, counseling, 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 progress. 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.

9.8.2 Boundaries and Relationships

The Procedure resource should not be used to capture an event if a more specific resource already exists - i.e. immunizations, drug administrations and communications. The boundary between determining whether an action is considered to be training or counseling (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.

Some diagnostic procedures may not have a Procedure record.  The Procedure record is only necessary when there is a need to capture information about the physical intervention that was performed to capture the diagnostic information (e.g. anesthetic, incision, scope size, etc.)

PLANNED CHANGE:

Procedure is one of the Event resources in the FHIR Workflow specification. As such, it is expected to be adjusted to align with the Event workflow pattern which will involve adding a number of additional data elements and potentially renaming a few elements. Any concerns about performing such alignment are welcome as ballot comments and/or tracker items.

This resource is referenced by Claim, ClinicalImpression, Encounter, ExplanationOfBenefit, Flag, ImagingStudy and QuestionnaireResponse

9.8.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure IDomainResourceAn action that is being or was performed on a patient
Reason not performed is only permitted if notPerformed indicator is true
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... subject Σ1..1Reference(Patient | Group)Who the procedure was performed on
... status ?!Σ1..1codein-progress | aborted | completed | entered-in-error
ProcedureStatus (Required)
... category Σ0..1CodeableConceptClassification of the procedure
Procedure Category Codes (SNOMED CT) (Example)
... code Σ1..1CodeableConceptIdentification of the procedure
Procedure Codes (SNOMED CT) (Example)
... notPerformed ?!Σ0..1booleanTrue if procedure was not performed as scheduled
... reasonNotPerformed I0..*CodeableConceptReason procedure was not performed
Procedure Not Performed Reason (SNOMED-CT) (Example)
... bodySite Σ0..*CodeableConceptTarget body sites
SNOMED CT Body Structures (Example)
... reasonReference Σ0..*Reference(Condition)Condition that is the reason the procedure performed
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Procedure Reason Codes (Example)
... performer Σ0..*BackboneElementThe people who performed the procedure
.... actor Σ0..1Reference(Practitioner | Organization | Patient | RelatedPerson)The reference to the practitioner
.... role Σ0..1CodeableConceptThe role the actor was in
Procedure Performer Role Codes (Example)
... performed[x] Σ0..1Date/Period the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
... encounter Σ0..1Reference(Encounter)The encounter associated with the procedure
... location Σ0..1Reference(Location)Where the procedure happened
... outcome Σ0..1CodeableConceptThe result of procedure
Procedure Outcome Codes (SNOMED CT) (Example)
... report 0..*Reference(DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Condition/Problem/Diagnosis Codes (Example)
... followUp 0..*CodeableConceptInstructions for follow up
Procedure Follow up Codes (SNOMED CT) (Example)
... request 0..1Reference(CarePlan | DiagnosticRequest | ProcedureRequest | ReferralRequest)A request for this procedure
... notes 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementDevice changed in procedure
.... action 0..1CodeableConceptKind of change to device
Procedure Device Action Codes (Required)
.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
... component 0..*Reference(MedicationAdministration | Procedure | Observation)Events related to the procedure

doco Documentation for this format

UML Diagram (Legend)

Procedure (DomainResource)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)identifier : Identifier [0..*]The person, animal or group on which the procedure was performedsubject : Reference [1..1] « Patient|Group »A code specifying the state of the procedure. Generally this will be in-progress or completed state (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the procedure. (Strength=Required)ProcedureStatus! »A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure")category : CodeableConcept [0..1] « A code that classifies a procedure for searching, sorting and display purposes. (Strength=Example)Procedure Category Codes (SNO...?? »The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy")code : CodeableConcept [1..1] « A code to identify a specific procedure . (Strength=Example)Procedure Codes (SNOMED CT)?? »Set this to true if the record is saying that the procedure was NOT performed (this element modifies the meaning of other elements)notPerformed : boolean [0..1]A code indicating why the procedure was not performedreasonNotPerformed : CodeableConcept [0..*] « A code that identifies the reason a procedure was not performed. (Strength=Example)Procedure Not Performed Reaso...?? »Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesionbodySite : CodeableConcept [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMED CT Body Structures?? »The condition that is the reason why the procedure was performedreasonReference : Reference [0..*] « Condition »The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as textreasonCode : CodeableConcept [0..*] « A code that identifies the reason a procedure is required. (Strength=Example)Procedure Reason ?? »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 capturedperformed[x] : Type [0..1] « dateTime|Period »The encounter during which the procedure was performedencounter : Reference [0..1] « Encounter »The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurantlocation : Reference [0..1] « Location »The outcome of the procedure - did it resolve reasons for the procedure being performed?outcome : CodeableConcept [0..1] « An outcome of a procedure - whether it was resolved or otherwise. (Strength=Example)Procedure Outcome Codes (SNOM...?? »This could be a histology result, pathology report, surgical report, etc.report : Reference [0..*] « DiagnosticReport »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' issuescomplication : CodeableConcept [0..*] « Codes describing complications that resulted from a procedure. (Strength=Example)Condition/Problem/Diagnosis ?? »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 usedfollowUp : CodeableConcept [0..*] « Specific follow up required for a procedure e.g. removal of sutures. (Strength=Example)Procedure Follow up Codes (SN...?? »A reference to a resource that contains details of the request for this procedurerequest : Reference [0..1] « CarePlan|DiagnosticRequest| ProcedureRequest|ReferralRequest »Any other notes about the procedure. E.g. the operative notesnotes : Annotation [0..*]Identifies medications, devices and any other substance used as part of the procedureusedReference : Reference [0..*] « Device|Medication|Substance »Identifies coded items that were used as part of the procedureusedCode : CodeableConcept [0..*]Identifies medication administrations, other procedures or observations that are related to this procedurecomponent : Reference [0..*] « MedicationAdministration|Procedure| Observation »PerformerThe practitioner who was involved in the procedureactor : Reference [0..1] « Practitioner|Organization|Patient| RelatedPerson »For example: surgeon, anaethetist, endoscopistrole : CodeableConcept [0..1] « A code that identifies the role of a performer of the procedure. (Strength=Example)Procedure Performer Role ?? »FocalDeviceThe kind of change that happened to the device during the procedureaction : CodeableConcept [0..1] « A kind of change that happened to the device during the procedure. (Strength=Required)Procedure Device Action ! »The device that was manipulated (changed) during the proceduremanipulated : Reference [1..1] « Device »Limited to 'real' people rather than equipmentperformer[0..*]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 ProcedurefocalDevice[0..*]

XML Template

<Procedure xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Identifiers for this procedure --></identifier>
 <subject><!-- 1..1 Reference(Patient|Group) Who the procedure was performed on --></subject>
 <status value="[code]"/><!-- 1..1 in-progress | aborted | completed | entered-in-error -->
 <category><!-- 0..1 CodeableConcept Classification of the procedure --></category>
 <code><!-- 1..1 CodeableConcept Identification of the procedure --></code>
 <notPerformed value="[boolean]"/><!-- 0..1 True if procedure was not performed as scheduled -->
 <reasonNotPerformed><!-- ?? 0..* CodeableConcept Reason procedure was not performed --></reasonNotPerformed>
 <bodySite><!-- 0..* CodeableConcept Target body sites --></bodySite>
 <reasonReference><!-- 0..* Reference(Condition) Condition that is the reason the procedure performed --></reasonReference>
 <reasonCode><!-- 0..* CodeableConcept Coded reason procedure performed --></reasonCode>
 <performer>  <!-- 0..* The people who performed the procedure -->
  <actor><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) The reference to the practitioner --></actor>
  <role><!-- 0..1 CodeableConcept The role the actor 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 associated with the procedure --></encounter>
 <location><!-- 0..1 Reference(Location) Where the procedure happened --></location>
 <outcome><!-- 0..1 CodeableConcept The result of procedure --></outcome>
 <report><!-- 0..* Reference(DiagnosticReport) Any report resulting from the procedure --></report>
 <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication>
 <followUp><!-- 0..* CodeableConcept Instructions for follow up --></followUp>
 <request><!-- 0..1 Reference(CarePlan|DiagnosticRequest|ProcedureRequest|
   ReferralRequest) A request for this procedure --></request>
 <notes><!-- 0..* Annotation Additional information about the procedure --></notes>
 <focalDevice>  <!-- 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>
 </focalDevice>
 <usedReference><!-- 0..* Reference(Device|Medication|Substance) Items used during procedure --></usedReference>
 <usedCode><!-- 0..* CodeableConcept Coded items used during the procedure --></usedCode>
 <component><!-- 0..* Reference(MedicationAdministration|Procedure|Observation) Events related to the procedure --></component>
</Procedure>

JSON Template

{doco
  "resourceType" : "Procedure",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Identifiers for this procedure
  "subject" : { Reference(Patient|Group) }, // R!  Who the procedure was performed on
  "status" : "<code>", // R!  in-progress | aborted | completed | entered-in-error
  "category" : { CodeableConcept }, // Classification of the procedure
  "code" : { CodeableConcept }, // R!  Identification of the procedure
  "notPerformed" : <boolean>, // True if procedure was not performed as scheduled
  "reasonNotPerformed" : [{ CodeableConcept }], // C? Reason procedure was not performed
  "bodySite" : [{ CodeableConcept }], // Target body sites
  "reasonReference" : [{ Reference(Condition) }], // Condition that is the reason the procedure performed
  "reasonCode" : [{ CodeableConcept }], // Coded reason procedure performed
  "performer" : [{ // The people who performed the procedure
    "actor" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }, // The reference to the practitioner
    "role" : { CodeableConcept } // The role the actor was in
  }],
  // performed[x]: Date/Period the procedure was performed. One of these 2:
  "performedDateTime" : "<dateTime>",
  "performedPeriod" : { Period },
  "encounter" : { Reference(Encounter) }, // The encounter associated with the procedure
  "location" : { Reference(Location) }, // Where the procedure happened
  "outcome" : { CodeableConcept }, // The result of procedure
  "report" : [{ Reference(DiagnosticReport) }], // Any report resulting from the procedure
  "complication" : [{ CodeableConcept }], // Complication following the procedure
  "followUp" : [{ CodeableConcept }], // Instructions for follow up
  "request" : { Reference(CarePlan|DiagnosticRequest|ProcedureRequest|
   ReferralRequest) }, // A request for this procedure
  "notes" : [{ Annotation }], // Additional information about the procedure
  "focalDevice" : [{ // Device changed in procedure
    "action" : { CodeableConcept }, // Kind of change to device
    "manipulated" : { Reference(Device) } // R!  Device that was changed
  }],
  "usedReference" : [{ Reference(Device|Medication|Substance) }], // Items used during procedure
  "usedCode" : [{ CodeableConcept }], // Coded items used during the procedure
  "component" : [{ Reference(MedicationAdministration|Procedure|Observation) }] // Events related to the procedure
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Procedure;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Procedure.identifier [ Identifier ], ... ; # 0..* External Identifiers for this procedure
  fhir:Procedure.subject [ Reference(Patient|Group) ]; # 1..1 Who the procedure was performed on
  fhir:Procedure.status [ code ]; # 1..1 in-progress | aborted | completed | entered-in-error
  fhir:Procedure.category [ CodeableConcept ]; # 0..1 Classification of the procedure
  fhir:Procedure.code [ CodeableConcept ]; # 1..1 Identification of the procedure
  fhir:Procedure.notPerformed [ boolean ]; # 0..1 True if procedure was not performed as scheduled
  fhir:Procedure.reasonNotPerformed [ CodeableConcept ], ... ; # 0..* Reason procedure was not performed
  fhir:Procedure.bodySite [ CodeableConcept ], ... ; # 0..* Target body sites
  fhir:Procedure.reasonReference [ Reference(Condition) ], ... ; # 0..* Condition that is the reason the procedure performed
  fhir:Procedure.reasonCode [ CodeableConcept ], ... ; # 0..* Coded reason procedure performed
  fhir:Procedure.performer [ # 0..* The people who performed the procedure
    fhir:Procedure.performer.actor [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 The reference to the practitioner
    fhir:Procedure.performer.role [ CodeableConcept ]; # 0..1 The role the actor was in
  ], ...;
  # Procedure.performed[x] : 0..1 Date/Period the procedure was performed. One of these 2
    fhir:Procedure.performedDateTime [ dateTime ]
    fhir:Procedure.performedPeriod [ Period ]
  fhir:Procedure.encounter [ Reference(Encounter) ]; # 0..1 The encounter associated with the procedure
  fhir:Procedure.location [ Reference(Location) ]; # 0..1 Where the procedure happened
  fhir:Procedure.outcome [ CodeableConcept ]; # 0..1 The result of procedure
  fhir:Procedure.report [ Reference(DiagnosticReport) ], ... ; # 0..* Any report resulting from the procedure
  fhir:Procedure.complication [ CodeableConcept ], ... ; # 0..* Complication following the procedure
  fhir:Procedure.followUp [ CodeableConcept ], ... ; # 0..* Instructions for follow up
  fhir:Procedure.request [ Reference(CarePlan|DiagnosticRequest|ProcedureRequest|ReferralRequest) ]; # 0..1 A request for this procedure
  fhir:Procedure.notes [ Annotation ], ... ; # 0..* Additional information about the procedure
  fhir:Procedure.focalDevice [ # 0..* Device changed in procedure
    fhir:Procedure.focalDevice.action [ CodeableConcept ]; # 0..1 Kind of change to device
    fhir:Procedure.focalDevice.manipulated [ Reference(Device) ]; # 1..1 Device that was changed
  ], ...;
  fhir:Procedure.usedReference [ Reference(Device|Medication|Substance) ], ... ; # 0..* Items used during procedure
  fhir:Procedure.usedCode [ CodeableConcept ], ... ; # 0..* Coded items used during the procedure
  fhir:Procedure.component [ Reference(MedicationAdministration|Procedure|Observation) ], ... ; # 0..* Events related to the procedure
]

Changes since DSTU2

Procedure
Procedure.reasonReference added
Procedure.reasonCode added
Procedure.request Remove Reference(DiagnosticOrder), Add Reference(DiagnosticRequest)
Procedure.usedReference added
Procedure.usedCode added
Procedure.component added
Procedure.reason[x] deleted
Procedure.used deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure IDomainResourceAn action that is being or was performed on a patient
Reason not performed is only permitted if notPerformed indicator is true
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... subject Σ1..1Reference(Patient | Group)Who the procedure was performed on
... status ?!Σ1..1codein-progress | aborted | completed | entered-in-error
ProcedureStatus (Required)
... category Σ0..1CodeableConceptClassification of the procedure
Procedure Category Codes (SNOMED CT) (Example)
... code Σ1..1CodeableConceptIdentification of the procedure
Procedure Codes (SNOMED CT) (Example)
... notPerformed ?!Σ0..1booleanTrue if procedure was not performed as scheduled
... reasonNotPerformed I0..*CodeableConceptReason procedure was not performed
Procedure Not Performed Reason (SNOMED-CT) (Example)
... bodySite Σ0..*CodeableConceptTarget body sites
SNOMED CT Body Structures (Example)
... reasonReference Σ0..*Reference(Condition)Condition that is the reason the procedure performed
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Procedure Reason Codes (Example)
... performer Σ0..*BackboneElementThe people who performed the procedure
.... actor Σ0..1Reference(Practitioner | Organization | Patient | RelatedPerson)The reference to the practitioner
.... role Σ0..1CodeableConceptThe role the actor was in
Procedure Performer Role Codes (Example)
... performed[x] Σ0..1Date/Period the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
... encounter Σ0..1Reference(Encounter)The encounter associated with the procedure
... location Σ0..1Reference(Location)Where the procedure happened
... outcome Σ0..1CodeableConceptThe result of procedure
Procedure Outcome Codes (SNOMED CT) (Example)
... report 0..*Reference(DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Condition/Problem/Diagnosis Codes (Example)
... followUp 0..*CodeableConceptInstructions for follow up
Procedure Follow up Codes (SNOMED CT) (Example)
... request 0..1Reference(CarePlan | DiagnosticRequest | ProcedureRequest | ReferralRequest)A request for this procedure
... notes 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementDevice changed in procedure
.... action 0..1CodeableConceptKind of change to device
Procedure Device Action Codes (Required)
.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
... component 0..*Reference(MedicationAdministration | Procedure | Observation)Events related to the procedure

doco Documentation for this format

UML Diagram (Legend)

Procedure (DomainResource)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)identifier : Identifier [0..*]The person, animal or group on which the procedure was performedsubject : Reference [1..1] « Patient|Group »A code specifying the state of the procedure. Generally this will be in-progress or completed state (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the procedure. (Strength=Required)ProcedureStatus! »A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure")category : CodeableConcept [0..1] « A code that classifies a procedure for searching, sorting and display purposes. (Strength=Example)Procedure Category Codes (SNO...?? »The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy")code : CodeableConcept [1..1] « A code to identify a specific procedure . (Strength=Example)Procedure Codes (SNOMED CT)?? »Set this to true if the record is saying that the procedure was NOT performed (this element modifies the meaning of other elements)notPerformed : boolean [0..1]A code indicating why the procedure was not performedreasonNotPerformed : CodeableConcept [0..*] « A code that identifies the reason a procedure was not performed. (Strength=Example)Procedure Not Performed Reaso...?? »Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesionbodySite : CodeableConcept [0..*] « Codes describing anatomical locations. May include laterality. (Strength=Example)SNOMED CT Body Structures?? »The condition that is the reason why the procedure was performedreasonReference : Reference [0..*] « Condition »The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as textreasonCode : CodeableConcept [0..*] « A code that identifies the reason a procedure is required. (Strength=Example)Procedure Reason ?? »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 capturedperformed[x] : Type [0..1] « dateTime|Period »The encounter during which the procedure was performedencounter : Reference [0..1] « Encounter »The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurantlocation : Reference [0..1] « Location »The outcome of the procedure - did it resolve reasons for the procedure being performed?outcome : CodeableConcept [0..1] « An outcome of a procedure - whether it was resolved or otherwise. (Strength=Example)Procedure Outcome Codes (SNOM...?? »This could be a histology result, pathology report, surgical report, etc.report : Reference [0..*] « DiagnosticReport »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' issuescomplication : CodeableConcept [0..*] « Codes describing complications that resulted from a procedure. (Strength=Example)Condition/Problem/Diagnosis ?? »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 usedfollowUp : CodeableConcept [0..*] « Specific follow up required for a procedure e.g. removal of sutures. (Strength=Example)Procedure Follow up Codes (SN...?? »A reference to a resource that contains details of the request for this procedurerequest : Reference [0..1] « CarePlan|DiagnosticRequest| ProcedureRequest|ReferralRequest »Any other notes about the procedure. E.g. the operative notesnotes : Annotation [0..*]Identifies medications, devices and any other substance used as part of the procedureusedReference : Reference [0..*] « Device|Medication|Substance »Identifies coded items that were used as part of the procedureusedCode : CodeableConcept [0..*]Identifies medication administrations, other procedures or observations that are related to this procedurecomponent : Reference [0..*] « MedicationAdministration|Procedure| Observation »PerformerThe practitioner who was involved in the procedureactor : Reference [0..1] « Practitioner|Organization|Patient| RelatedPerson »For example: surgeon, anaethetist, endoscopistrole : CodeableConcept [0..1] « A code that identifies the role of a performer of the procedure. (Strength=Example)Procedure Performer Role ?? »FocalDeviceThe kind of change that happened to the device during the procedureaction : CodeableConcept [0..1] « A kind of change that happened to the device during the procedure. (Strength=Required)Procedure Device Action ! »The device that was manipulated (changed) during the proceduremanipulated : Reference [1..1] « Device »Limited to 'real' people rather than equipmentperformer[0..*]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 ProcedurefocalDevice[0..*]

XML Template

<Procedure xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier External Identifiers for this procedure --></identifier>
 <subject><!-- 1..1 Reference(Patient|Group) Who the procedure was performed on --></subject>
 <status value="[code]"/><!-- 1..1 in-progress | aborted | completed | entered-in-error -->
 <category><!-- 0..1 CodeableConcept Classification of the procedure --></category>
 <code><!-- 1..1 CodeableConcept Identification of the procedure --></code>
 <notPerformed value="[boolean]"/><!-- 0..1 True if procedure was not performed as scheduled -->
 <reasonNotPerformed><!-- ?? 0..* CodeableConcept Reason procedure was not performed --></reasonNotPerformed>
 <bodySite><!-- 0..* CodeableConcept Target body sites --></bodySite>
 <reasonReference><!-- 0..* Reference(Condition) Condition that is the reason the procedure performed --></reasonReference>
 <reasonCode><!-- 0..* CodeableConcept Coded reason procedure performed --></reasonCode>
 <performer>  <!-- 0..* The people who performed the procedure -->
  <actor><!-- 0..1 Reference(Practitioner|Organization|Patient|RelatedPerson) The reference to the practitioner --></actor>
  <role><!-- 0..1 CodeableConcept The role the actor 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 associated with the procedure --></encounter>
 <location><!-- 0..1 Reference(Location) Where the procedure happened --></location>
 <outcome><!-- 0..1 CodeableConcept The result of procedure --></outcome>
 <report><!-- 0..* Reference(DiagnosticReport) Any report resulting from the procedure --></report>
 <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication>
 <followUp><!-- 0..* CodeableConcept Instructions for follow up --></followUp>
 <request><!-- 0..1 Reference(CarePlan|DiagnosticRequest|ProcedureRequest|
   ReferralRequest) A request for this procedure --></request>
 <notes><!-- 0..* Annotation Additional information about the procedure --></notes>
 <focalDevice>  <!-- 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>
 </focalDevice>
 <usedReference><!-- 0..* Reference(Device|Medication|Substance) Items used during procedure --></usedReference>
 <usedCode><!-- 0..* CodeableConcept Coded items used during the procedure --></usedCode>
 <component><!-- 0..* Reference(MedicationAdministration|Procedure|Observation) Events related to the procedure --></component>
</Procedure>

JSON Template

{doco
  "resourceType" : "Procedure",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // External Identifiers for this procedure
  "subject" : { Reference(Patient|Group) }, // R!  Who the procedure was performed on
  "status" : "<code>", // R!  in-progress | aborted | completed | entered-in-error
  "category" : { CodeableConcept }, // Classification of the procedure
  "code" : { CodeableConcept }, // R!  Identification of the procedure
  "notPerformed" : <boolean>, // True if procedure was not performed as scheduled
  "reasonNotPerformed" : [{ CodeableConcept }], // C? Reason procedure was not performed
  "bodySite" : [{ CodeableConcept }], // Target body sites
  "reasonReference" : [{ Reference(Condition) }], // Condition that is the reason the procedure performed
  "reasonCode" : [{ CodeableConcept }], // Coded reason procedure performed
  "performer" : [{ // The people who performed the procedure
    "actor" : { Reference(Practitioner|Organization|Patient|RelatedPerson) }, // The reference to the practitioner
    "role" : { CodeableConcept } // The role the actor was in
  }],
  // performed[x]: Date/Period the procedure was performed. One of these 2:
  "performedDateTime" : "<dateTime>",
  "performedPeriod" : { Period },
  "encounter" : { Reference(Encounter) }, // The encounter associated with the procedure
  "location" : { Reference(Location) }, // Where the procedure happened
  "outcome" : { CodeableConcept }, // The result of procedure
  "report" : [{ Reference(DiagnosticReport) }], // Any report resulting from the procedure
  "complication" : [{ CodeableConcept }], // Complication following the procedure
  "followUp" : [{ CodeableConcept }], // Instructions for follow up
  "request" : { Reference(CarePlan|DiagnosticRequest|ProcedureRequest|
   ReferralRequest) }, // A request for this procedure
  "notes" : [{ Annotation }], // Additional information about the procedure
  "focalDevice" : [{ // Device changed in procedure
    "action" : { CodeableConcept }, // Kind of change to device
    "manipulated" : { Reference(Device) } // R!  Device that was changed
  }],
  "usedReference" : [{ Reference(Device|Medication|Substance) }], // Items used during procedure
  "usedCode" : [{ CodeableConcept }], // Coded items used during the procedure
  "component" : [{ Reference(MedicationAdministration|Procedure|Observation) }] // Events related to the procedure
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:Procedure;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:Procedure.identifier [ Identifier ], ... ; # 0..* External Identifiers for this procedure
  fhir:Procedure.subject [ Reference(Patient|Group) ]; # 1..1 Who the procedure was performed on
  fhir:Procedure.status [ code ]; # 1..1 in-progress | aborted | completed | entered-in-error
  fhir:Procedure.category [ CodeableConcept ]; # 0..1 Classification of the procedure
  fhir:Procedure.code [ CodeableConcept ]; # 1..1 Identification of the procedure
  fhir:Procedure.notPerformed [ boolean ]; # 0..1 True if procedure was not performed as scheduled
  fhir:Procedure.reasonNotPerformed [ CodeableConcept ], ... ; # 0..* Reason procedure was not performed
  fhir:Procedure.bodySite [ CodeableConcept ], ... ; # 0..* Target body sites
  fhir:Procedure.reasonReference [ Reference(Condition) ], ... ; # 0..* Condition that is the reason the procedure performed
  fhir:Procedure.reasonCode [ CodeableConcept ], ... ; # 0..* Coded reason procedure performed
  fhir:Procedure.performer [ # 0..* The people who performed the procedure
    fhir:Procedure.performer.actor [ Reference(Practitioner|Organization|Patient|RelatedPerson) ]; # 0..1 The reference to the practitioner
    fhir:Procedure.performer.role [ CodeableConcept ]; # 0..1 The role the actor was in
  ], ...;
  # Procedure.performed[x] : 0..1 Date/Period the procedure was performed. One of these 2
    fhir:Procedure.performedDateTime [ dateTime ]
    fhir:Procedure.performedPeriod [ Period ]
  fhir:Procedure.encounter [ Reference(Encounter) ]; # 0..1 The encounter associated with the procedure
  fhir:Procedure.location [ Reference(Location) ]; # 0..1 Where the procedure happened
  fhir:Procedure.outcome [ CodeableConcept ]; # 0..1 The result of procedure
  fhir:Procedure.report [ Reference(DiagnosticReport) ], ... ; # 0..* Any report resulting from the procedure
  fhir:Procedure.complication [ CodeableConcept ], ... ; # 0..* Complication following the procedure
  fhir:Procedure.followUp [ CodeableConcept ], ... ; # 0..* Instructions for follow up
  fhir:Procedure.request [ Reference(CarePlan|DiagnosticRequest|ProcedureRequest|ReferralRequest) ]; # 0..1 A request for this procedure
  fhir:Procedure.notes [ Annotation ], ... ; # 0..* Additional information about the procedure
  fhir:Procedure.focalDevice [ # 0..* Device changed in procedure
    fhir:Procedure.focalDevice.action [ CodeableConcept ]; # 0..1 Kind of change to device
    fhir:Procedure.focalDevice.manipulated [ Reference(Device) ]; # 1..1 Device that was changed
  ], ...;
  fhir:Procedure.usedReference [ Reference(Device|Medication|Substance) ], ... ; # 0..* Items used during procedure
  fhir:Procedure.usedCode [ CodeableConcept ], ... ; # 0..* Coded items used during the procedure
  fhir:Procedure.component [ Reference(MedicationAdministration|Procedure|Observation) ], ... ; # 0..* Events related to the procedure
]

Changes since DSTU2

Procedure
Procedure.reasonReference added
Procedure.reasonCode added
Procedure.request Remove Reference(DiagnosticOrder), Add Reference(DiagnosticRequest)
Procedure.usedReference added
Procedure.usedCode added
Procedure.component added
Procedure.reason[x] deleted
Procedure.used deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle)

9.8.3.1 Terminology Bindings

PathDefinitionTypeReference
Procedure.status A code specifying the state of the procedure.RequiredProcedureStatus
Procedure.category A code that classifies a procedure for searching, sorting and display purposes.ExampleProcedure Category Codes (SNOMED CT)
Procedure.code A code to identify a specific procedure .ExampleProcedure Codes (SNOMED CT)
Procedure.reasonNotPerformed A code that identifies the reason a procedure was not performed.ExampleProcedure Not Performed Reason (SNOMED-CT)
Procedure.bodySite Codes describing anatomical locations. May include laterality.ExampleSNOMED CT Body Structures
Procedure.reasonCode A code that identifies the reason a procedure is required.ExampleProcedure Reason Codes
Procedure.performer.role A code that identifies the role of a performer of the procedure.ExampleProcedure Performer Role Codes
Procedure.outcome An outcome of a procedure - whether it was resolved or otherwise.ExampleProcedure Outcome Codes (SNOMED CT)
Procedure.complication Codes describing complications that resulted from a procedure.ExampleCondition/Problem/Diagnosis Codes
Procedure.followUp Specific follow up required for a procedure e.g. removal of sutures.ExampleProcedure Follow up Codes (SNOMED CT)
Procedure.focalDevice.action A kind of change that happened to the device during the procedure.RequiredProcedure Device Action Codes
Procedure.usedCode Codes describing items used during a procedureUnknownNo details provided yet

9.8.3.2 Constraints

  • pro-1: Reason not performed is only permitted if notPerformed indicator is true (expression : reasonNotPerformed.empty() or notPerformed = true)

9.8.3.3 Use of Procedure properties

Many of the elements of Procedure have inherent relationships and may actually all be conveyed by the Procedure.code or in the text element of the Procedure.code property. I.e. You may be able to infer category, bodySite and even indication. Whether these other properties will be populated may vary by implementation.

Care should be taken to avoid nonsensical combinations/statements; e.g. "name=amputation, bodySite=heart"

9.8.3.4 Use of Procedure.used

For devices, these are devices that are incidental to / or used to perform the procedure - scalpels, gauze, endoscopes, etc. Devices that are the focus of the procedure should appear in Procedure.device instead.

9.8.4 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
categorytokenClassification of the procedureProcedure.category
codetokenA code to identify a procedureProcedure.code
datedateDate/Period the procedure was performedProcedure.performed[x]
encounterreferenceThe encounter associated with the procedureProcedure.encounter
(Encounter)
identifiertokenA unique identifier for a procedureProcedure.identifier
locationreferenceWhere the procedure happenedProcedure.location
(Location)
patientreferenceSearch by subject - a patientProcedure.subject
(Patient)
performerreferenceThe reference to the practitionerProcedure.performer.actor
(Practitioner, Organization, Patient, RelatedPerson)
subjectreferenceSearch by subjectProcedure.subject
(Group, Patient)