This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions
Definitions for the procedure-daf-dafprocedure Profile.
Procedure(DAFProcedure) | |
Definition | An action that is performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counseling or hypnotherapy. |
Control | 1..1 |
Type | Procedure |
Procedure.id | |
Definition | The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes. |
Control | 0..1 |
Type | id |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID. |
Procedure.meta | |
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
Control | 0..1 |
Type | Meta |
Procedure.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible. |
Procedure.language | |
Definition | The base language in which the resource is written. |
Control | 0..1 |
Binding | A human language The codes SHALL be taken from http://tools.ietf.org/html/bcp47 |
Type | code |
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). |
Procedure.text | |
Definition | A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. |
Control | 0..1 This element is affected by the following invariants: dom-1 |
Type | Narrative |
Alternate Names | narrative, html, xhtml, display |
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. |
Procedure.contained | |
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. |
Control | 0..* |
Type | Resource |
Alternate Names | inline resources, anonymous resources, contained resources |
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. |
Procedure.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.identifier | |
Definition | This records identifiers associated with this procedure that are defined by business processed 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). |
Control | 1..* |
Type | Identifier |
Must Support | true |
Requirements | Need to allow connection to a wider workflow. |
Procedure.patient | |
Definition | The person on whom the procedure was performed. |
Control | 1..1 |
Type | Reference (U.S. Data Access Framework (DAF) Patient Profile)) |
Must Support | true |
Procedure.status | |
Definition | A code specifying the state of the procedure record. Generally this will be in-progress or completed state. |
Control | 1..1 |
Binding | A code specifying the state of the procedure record The codes SHALL be taken from ProcedureStatus |
Type | code |
Procedure.category | |
Definition | A code that classifies the procedure for searching, sorting and display purposes. |
Control | 0..1 |
Binding | A code that classifies a procedure for searching, sorting and display purposes For example codes, see Procedure Category Codes (SNOMED CT) |
Type | CodeableConcept |
Procedure.type | |
Definition | SNOMED-CT | ICD-10 | CPT-4. |
Control | 1..1 |
Binding | Codes describing the Procedure Type The codes SHALL be taken from DAFProcedureType; other codes may be used where these codes are not suitable |
Type | CodeableConcept |
Must Support | true |
Procedure.bodySite | |
Definition | Coded Responses fromBody Site Value Set. |
Control | 0..* |
Binding | Codes describing anatomical locations The codes SHALL be taken from SNOMED CT Body Structures; other codes may be used where these codes are not suitable |
Type | CodeableConcept |
Must Support | true |
Procedure.bodySite.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Procedure.bodySite.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.bodySite.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.bodySite.site[x] | |
Definition | Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. |
Control | 1..1 |
Type | Choice of: CodeableConcept, Reference (BodySite)) |
Procedure.indication | |
Definition | The 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. |
Control | 0..* |
Type | CodeableConcept |
Comments | e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapuetic. |
Procedure.performer | |
Definition | Limited to 'real' people rather than equipment. |
Control | 0..* |
Type | Element |
Must Support | true |
Procedure.performer.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Procedure.performer.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.performer.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.performer.person | |
Definition | The practitioner who was involved in the procedure. |
Control | 0..1 |
Type | Reference (U.S. Data Access Framework (DAF) Practitioner Profile)) |
Must Support | true |
Procedure.performer.role | |
Definition | E.g. surgeon, anaethetist, endoscopist. |
Control | 0..1 |
Type | CodeableConcept |
Procedure.performed[x] | |
Definition | 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. |
Control | 0..1 |
Type | Choice of: dateTime, Period |
Must Support | true |
Procedure.encounter | |
Definition | The encounter during which the procedure was performed. |
Control | 0..1 |
Type | Reference (U.S. Data Access Framework (DAF) Encounter profile)) |
Must Support | true |
Procedure.location | |
Definition | The location where the procedure actually happened. e.g. a newborn at home, a tracheostomy at a restaurant. |
Control | 0..1 |
Type | Reference (Location)) |
Comments | Ties a procedure to where the records are kept. |
Procedure.outcome | |
Definition | What was the outcome of the procedure - did it resolve reasons why the procedure was performed? |
Control | 0..1 |
Binding | The outcome of a procedure - whether it resolveed the reasons why the procedure was performed For example codes, see Procedure Outcome Codes (SNOMED CT) |
Type | CodeableConcept |
Procedure.report | |
Definition | This could be a histology result. There could potentially be multiple reports - e.g. if this was a procedure that made multiple biopsies. |
Control | 0..* |
Type | Reference (DiagnosticReport)) |
Procedure.complication | |
Definition | Any complications that occurred during the procedure, or in the immediate post-operative period. These are generally tracked separately from the notes, which typically will describe the procedure itself rather than any 'post procedure' issues. |
Control | 0..* |
Type | CodeableConcept |
Procedure.followUp | |
Definition | If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or potentially could be more complex in which case the CarePlan resource can be used. |
Control | 0..* |
Binding | Specific follow up required for a procedure e.g. removal of sutures For example codes, see Procedure Follow up Codes (SNOMED CT) |
Type | CodeableConcept |
Procedure.relatedItem | |
Definition | Procedures may be related to other items such as procedures or medications. For example treating wound dehiscence following a previous procedure. |
Control | 0..* |
Type | null |
Procedure.relatedItem.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Procedure.relatedItem.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.relatedItem.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.relatedItem.type | |
Definition | The nature of the relationship. |
Control | 0..1 |
Binding | The nature of the relationship with this procedure The codes SHALL be taken from ProcedureRelationshipType |
Type | code |
Procedure.relatedItem.target | |
Definition | The related item - e.g. a procedure. |
Control | 0..1 |
Type | Choice of: Reference (AllergyIntolerance)), Reference (CarePlan)), Reference (Condition)), Reference (DiagnosticReport)), Reference (FamilyHistory)), Reference (ImagingStudy)), Reference (Immunization)), Reference (ImmunizationRecommendation)), Reference (MedicationAdministration)), Reference (MedicationDispense)), Reference (MedicationPrescription)), Reference (MedicationStatement)), Reference (Observation)), Reference (Procedure)) |
Procedure.notes | |
Definition | Any other notes about the procedure - e.g. the operative notes. |
Control | 0..1 |
Type | string |
Procedure.device | |
Definition | A device change during the procedure. |
Control | 0..* |
Type | null |
Procedure.device.id | |
Definition | unique id for the element within a resource (for internal references). |
Control | 0..1 |
Type | id |
Procedure.device.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.device.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content, modifiers |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Procedure.device.action | |
Definition | The kind of change that happened to the device during the procedure. |
Control | 0..1 |
Binding | The kind of change that happened to the device during the procedure The codes SHALL be taken from Procedure Device Action Codes |
Type | CodeableConcept |
Procedure.device.manipulated | |
Definition | The device that was manipulated (changed) during the procedure. |
Control | 1..1 |
Type | Reference (Device)) |