Procedure - FHIR v0.0.82

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 . Page versions: R5 R4B R4 R3 R2

4.6.5 Resource Procedure - Formal Definitions

Formal definitions for the elements in the Procedure resource.

Procedure
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
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	0..*
Type	Identifier
Requirements	Need to allow connection to a wider workflow.
Summary	true
Procedure.subject
Definition	The person on whom the procedure was performed.
Control	1..1
Type	Resource(Patient)
Summary	true
Procedure.type
Definition	The specific procedure that is performed. Use text if the exact nature of the procedure can't be coded.
Control	1..1
Type	CodeableConcept
Summary	true
Procedure.bodySite
Definition	Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
Control	0..*
Type	CodeableConcept
Summary	true
To Do	Is this approach or target site?.
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
Summary	true
Comments	e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapuetic.
Procedure.performer
Definition	Limited to 'real' people rather than equipment.
Control	0..*
Summary	true
Procedure.performer.person
Definition	The practitioner who was involved in the procedure.
Control	0..1
Type	Resource(Practitioner)
Summary	true
Procedure.performer.role
Definition	E.g. surgeon, anaethetist, endoscopist.
Control	0..1
Type	CodeableConcept
Summary	true
Procedure.date
Definition	The dates over which the procedure was performed. Allows a period to support complex procedures that span more that one date, and also allows for the length of the procedure to be captured.
Control	0..1
Type	Period
Summary	true
Procedure.encounter
Definition	The encounter during which the procedure was performed.
Control	0..1
Type	Resource(Encounter)
Summary	true
Procedure.outcome
Definition	What was the outcome of the procedure - did it resolve reasons why the procedure was performed?.
Control	0..1
Type	string
Summary	true
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	Resource(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
To Do	Need harmonization proposal for new ActRelationshipType code.
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..1
Type	string
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..*
Procedure.relatedItem.type
Definition	The nature of the relationship.
Control	0..1
Binding	ProcedureRelationshipType: The nature of the relationship with this procedure (see http://hl7.org/fhir/procedure-relationship-type for values)
Type	code
To Do	Existing codes sound like synonyms. Suggest caused-by and caused.
Procedure.relatedItem.target
Definition	The related item - e.g. a procedure.
Control	0..1
Type	Resource(AdverseReaction \| AllergyIntolerance \| CarePlan \| Condition \| DeviceObservationReport \| DiagnosticReport \| FamilyHistory \| ImagingStudy \| Immunization \| ImmunizationRecommendation \| MedicationAdministration \| MedicationDispense \| MedicationPrescription \| MedicationStatement \| Observation \| Procedure)
Procedure.notes
Definition	Any other notes about the procedure - e.g. the operative notes.
Control	0..1
Type	string