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.

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).

Need to allow connection to a wider workflow.

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

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

The person, animal or group on which the procedure was performed.

The encounter during which the procedure was performed.

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.

Limited to 'real' people rather than equipment.

The practitioner who was involved in the procedure.

For example: surgeon, anaethetist, endoscopist.

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

Ties a procedure to where the records are likely kept.

The condition that is the reason why the procedure was performed.

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

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

Set this to true if the record is saying that the procedure was NOT performed.

If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome.

A code indicating why the procedure was not performed.

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

The outcome of the procedure - did it resolve reasons for the procedure being performed?

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

This could be a histology result, pathology report, surgical report, etc..

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

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.

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

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.

A reference to a resource that contains details of the request for this procedure.

Any other notes about the procedure. E.g. the operative notes.

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.

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

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

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

Used for tracking contamination, etc.

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

Identifies coded items that were used as part of the procedure.

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

Identifies medication administrations, other procedures or observations that are related to this procedure.