R6 Ballot (2nd Draft)

Publish-box (todo)

Patient Care icon Work GroupMaturity Level: N/AStandards Status: InformativeSecurity Category: Patient Compartments: Encounter, Patient, Practitioner, RelatedPerson

Mappings for the procedure resource (see Mappings to Other Standards for further information & status).

Procedure clinical.general
    identifier FiveWs.identifier
    status FiveWs.status
    category FiveWs.class
    code FiveWs.what[x]
    subject FiveWs.subject[x]
    focus FiveWs.subject[x]
    encounter FiveWs.context
    occurrence[x] FiveWs.done[x]
    recorded FiveWs.recorded
    recorder FiveWs.author
    reported[x] FiveWs.source
        actor FiveWs.actor
    location FiveWs.where[x]
    reason FiveWs.why[x]
Procedure Event
    identifier Event.identifier
    instantiatesCanonical Event.instantiatesCanonical
    instantiatesUri Event.instantiatesUri
    basedOn Event.basedOn
    partOf Event.partOf
    status Event.status
    statusReason Event.statusReason
    code Event.code
    subject Event.subject
    encounter Event.encounter
    occurrence[x] Event.occurrence[x]
    recorded Event.recorded
    reported[x] Event.reported[x]
    performer Event.performer
        function Event.performer.function
        actor Event.performer.actor
    reason Event.reason
    note Event.note
Procedure
    identifier PR1-19
    instantiatesCanonical
    instantiatesUri
    basedOn
    partOf PR1-25
    status
    statusReason
    category PR1-6
    code PR1-3
    subject PID-3
    focus
    encounter PV1-19
    occurrence[x] PR1-5 - occurrencePeriod.end can be inferred when both PR1-5 (Procedure Date/Time) and PR1-7 (Procedure Minutes) are populated
    recorded
    recorder
    reported[x]
    performer
        function Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25
        actor PR1-8 (Anesthesiologist), PR1-11 (Surgeon), PR1-12 (Procedure Practitioner) --> Procedure.performer.actor where Procedure.performer.function is also populated
        onBehalfOf
        period
    location PR1-23
    reason PR1-15
    bodySite OBX-20
    bodyStructure
    outcome
    report
    complication
    followUp
    note NTE
    focalDevice
        action
        manipulated
    used
    supportingInfo
Procedure Procedure[moodCode=EVN]
    identifier .id
    instantiatesCanonical .outboundRelationship[typeCode=DEFN].target
    instantiatesUri .outboundRelationship[typeCode=DEFN].target
    basedOn .outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
    partOf .inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
    status statusCode
    statusReason .reason.Observation.value
    category .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
    code .code
    subject .participation[typeCode=SBJ].role
    encounter .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
    occurrence[x] .effectiveTime
    recorded .participation[typeCode=AUT].time
    recorder .participation[typeCode=AUT].role
    reported[x] .participation[typeCode=RPT].role
    performer .participation[typeCode=PRF]
        function .functionCode
        actor .role
        onBehalfOf .scoper
    location .participation[typeCode=LOC].role[classCode=SDLOC]
    reason .reasonCode
    bodySite .targetSiteCode
    bodyStructure targetSiteCode
    outcome .outboundRelationship[typeCode=OUT].target.text
    report .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
    complication .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
    followUp .outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
    note .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
    focalDevice .participation[typeCode=DEV].role[classCode=MANU]
        action .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
        manipulated .participation[typeCode=DEV].role[classCode=SDLOC]
    used participation[typeCode=Dev].role[classCode=MANU]
    supportingInfo .outboundRelationship[typeCode=PERT].target