{ "resourceType": "StructureDefinition", "id": "ProcedureRequest", "meta": { "lastUpdated": "2019-10-24T11:53:00+11:00" }, "text": { "status": "generated", "div": "
\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
NameFlagsCard.TypeDescription & Constraints\"doco\"
\".\"\".\" ProcedureRequest DomainResourceA request for a procedure or diagnostic to be performed
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
\".\"\".\"\".\" identifier Σ0..*IdentifierIdentifiers assigned to this order
\".\"\".\"\".\" definition Σ0..*Reference(ActivityDefinition | PlanDefinition)Protocol or definition
\".\"\".\"\".\" basedOn Σ0..*Reference(Any)What request fulfills
\".\"\".\"\".\" replaces Σ0..*Reference(Any)What request replaces
\".\"\".\"\".\" requisition Σ0..1IdentifierComposite Request ID
\".\"\".\"\".\" status ?!Σ1..1codedraft | active | suspended | completed | entered-in-error | cancelled
RequestStatus (Required)
\".\"\".\"\".\" intent ?!Σ1..1codeproposal | plan | order +
RequestIntent (Required)
\".\"\".\"\".\" priority Σ0..1coderoutine | urgent | asap | stat
RequestPriority (Required)
\".\"\".\"\".\" doNotPerform ?!Σ0..1booleanTrue if procedure should not be performed
\".\"\".\"\".\" category Σ0..*CodeableConceptClassification of procedure
Procedure Category Codes (SNOMED CT) (Example)
\".\"\".\"\".\" code Σ1..1CodeableConceptWhat is being requested/ordered
Procedure Codes (SNOMED CT) (Example)
\".\"\".\"\".\" subject Σ1..1Reference(Patient | Group | Location | Device)Individual the service is ordered for
\".\"\".\"\".\" context Σ0..1Reference(Encounter | EpisodeOfCare)Encounter or Episode during which request was created
\".\"\".\"\".\" occurrence[x] Σ0..1When procedure should occur
\".\"\".\"\".\"\".\" occurrenceDateTimedateTime
\".\"\".\"\".\"\".\" occurrencePeriodPeriod
\".\"\".\"\".\"\".\" occurrenceTimingTiming
\".\"\".\"\".\" asNeeded[x] Σ0..1Preconditions for procedure or diagnostic
SNOMED CT Medication As Needed Reason Codes (Example)
\".\"\".\"\".\"\".\" asNeededBooleanboolean
\".\"\".\"\".\"\".\" asNeededCodeableConceptCodeableConcept
\".\"\".\"\".\" authoredOn Σ0..1dateTimeDate request signed
\".\"\".\"\".\" requester Σ0..1BackboneElementWho/what is requesting procedure or diagnostic
\".\"\".\"\".\"\".\" agent Σ1..1Reference(Device | Practitioner | Organization)Individual making the request
\".\"\".\"\".\"\".\" onBehalfOf Σ0..1Reference(Organization)Organization agent is acting for
\".\"\".\"\".\" performerType Σ0..1CodeableConceptPerformer role
Participant Roles (Example)
\".\"\".\"\".\" performer Σ0..1Reference(Practitioner | Organization | Patient | Device | RelatedPerson | HealthcareService)Requested perfomer
\".\"\".\"\".\" reasonCode Σ0..*CodeableConceptExplanation/Justification for test
Procedure Reason Codes (Example)
\".\"\".\"\".\" reasonReference Σ0..*Reference(Condition | Observation)Explanation/Justification for test
\".\"\".\"\".\" supportingInfo 0..*Reference(Any)Additional clinical information
\".\"\".\"\".\" specimen Σ0..*Reference(Specimen)Procedure Samples
\".\"\".\"\".\" bodySite Σ0..*CodeableConceptLocation on Body
SNOMED CT Body Structures (Example)
\".\"\".\"\".\" note 0..*AnnotationComments
\".\"\".\"\".\" relevantHistory 0..*Reference(Provenance)Request provenance

\"doco\" Documentation for this format
" }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm", "valueInteger": 3 }, { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg", "valueCode": "oo" } ], "url": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest", "name": "ProcedureRequest", "status": "draft", "date": "2019-10-24T11:53:00+11:00", "publisher": "Health Level Seven International (Orders and Observations)", "contact": [ { "telecom": [ { "system": "url", "value": "http://hl7.org/fhir" } ] }, { "telecom": [ { "system": "url", "value": "http://www.hl7.org/Special/committees/orders/index.cfm" } ] } ], "description": "Base StructureDefinition for ProcedureRequest Resource", "fhirVersion": "3.0.2", "mapping": [ { "identity": "workflow", "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Mapping" }, { "identity": "v2", "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping" }, { "identity": "rim", "uri": "http://hl7.org/v3", "name": "RIM Mapping" }, { "identity": "w5", "uri": "http://hl7.org/fhir/w5", "name": "W5 Mapping" }, { "identity": "quick", "uri": "http://wiki.siframework.org/CQF", "name": "Quality Improvement and Clinical Knowledge (QUICK)" } ], "kind": "resource", "abstract": false, "type": "ProcedureRequest", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource", "derivation": "specialization", "snapshot": { "element": [ { "id": "ProcedureRequest", "path": "ProcedureRequest", "short": "A request for a procedure or diagnostic to be performed", "definition": "A record of a request for diagnostic investigations, treatments, or operations to be performed.", "alias": [ "diagnostic request" ], "min": 0, "max": "*", "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)", "source": "DomainResource" }, { "key": "dom-1", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain any narrative", "expression": "contained.text.empty()", "xpath": "not(parent::f:contained and f:text)", "source": "DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source": "DomainResource" }, { "key": "dom-3", "severity": "error", "human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource", "expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()", "xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))", "source": "DomainResource" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Request" }, { "identity": "v2", "map": "ORC" }, { "identity": "rim", "map": "Act[moodCode<=INT]" }, { "identity": "w5", "map": "clinical.general" } ] }, { "id": "ProcedureRequest.id", "path": "ProcedureRequest.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "code": "id" } ], "isSummary": true }, { "id": "ProcedureRequest.meta", "path": "ProcedureRequest.meta", "short": "Metadata about the resource", "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.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "isSummary": true }, { "id": "ProcedureRequest.implicitRules", "path": "ProcedureRequest.implicitRules", "short": "A set of rules under which this content was created", "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.", "comment": "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "isModifier": true, "isSummary": true }, { "id": "ProcedureRequest.language", "path": "ProcedureRequest.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "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).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueReference": { "reference": "http://hl7.org/fhir/ValueSet/all-languages" } }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding", "valueBoolean": true } ], "strength": "extensible", "description": "A human language.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/languages" } } }, { "id": "ProcedureRequest.text", "path": "ProcedureRequest.text", "short": "Text summary of the resource, for human interpretation", "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.", "comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "dom-1" ], "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "id": "ProcedureRequest.contained", "path": "ProcedureRequest.contained", "short": "Contained, inline Resources", "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.", "comment": "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.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "ProcedureRequest.extension", "path": "ProcedureRequest.extension", "short": "Additional Content defined by implementations", "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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "ProcedureRequest.modifierExtension", "path": "ProcedureRequest.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "ProcedureRequest.identifier", "path": "ProcedureRequest.identifier", "short": "Identifiers assigned to this order", "definition": "Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller.", "comment": "The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.identifier" }, { "identity": "v2", "map": "ORC.2, ORC.3" }, { "identity": "rim", "map": ".identifier" }, { "identity": "quick", "map": "ClinicalStatement.identifier" }, { "identity": "w5", "map": "id" } ] }, { "id": "ProcedureRequest.definition", "path": "ProcedureRequest.definition", "short": "Protocol or definition", "definition": "Protocol or definition followed by this request.", "alias": [ "protocol" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ActivityDefinition" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/PlanDefinition" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.definition" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=DEFN].target" } ] }, { "id": "ProcedureRequest.basedOn", "path": "ProcedureRequest.basedOn", "short": "What request fulfills", "definition": "Plan/proposal/order fulfilled by this request.", "alias": [ "fulfills" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.basedOn" }, { "identity": "v2", "map": "ORC.8 (plus others)" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "ProcedureRequest.replaces", "path": "ProcedureRequest.replaces", "short": "What request replaces", "definition": "The request takes the place of the referenced completed or terminated request(s).", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.replaces" }, { "identity": "v2", "map": "Handled by message location of ORC (ORC.1=RO or RU)" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RPLC].target" } ] }, { "id": "ProcedureRequest.requisition", "path": "ProcedureRequest.requisition", "short": "Composite Request ID", "definition": "A shared identifier common to all procedure or diagnostic requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier.", "comment": "Requests are linked either by a \"basedOn\" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.", "requirements": "Some business processes need to know if multiple items were ordered as part of the same \"requisition\" for billing or other purposes.", "alias": [ "grouperId", "groupIdentifier" ], "min": 0, "max": "1", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ORC.4" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=COMP].source[moodCode=INT].identifier" } ] }, { "id": "ProcedureRequest.status", "path": "ProcedureRequest.status", "short": "draft | active | suspended | completed | entered-in-error | cancelled", "definition": "The status of the order.", "comment": "The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see [Event Pattern](event.html) for general discussion) or using the [Task](task.html) resource.\n\nThis element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestStatus" } ], "strength": "required", "description": "The status of a procedure or diagnostic order.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/request-status" } }, "mapping": [ { "identity": "workflow", "map": "Request.status" }, { "identity": "v2", "map": "ORC.5" }, { "identity": "rim", "map": ".status" }, { "identity": "quick", "map": "Action.currentStatus" }, { "identity": "w5", "map": "status" } ] }, { "id": "ProcedureRequest.intent", "path": "ProcedureRequest.intent", "short": "proposal | plan | order +", "definition": "Whether the request is a proposal, plan, an original order or a reflex order.", "comment": "This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestIntent" } ], "strength": "required", "description": "The kind of procedure or diagnostic request", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/request-intent" } }, "mapping": [ { "identity": "workflow", "map": "Request.intent" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".moodCode (nuances beyond PRP/PLAN/RQO would need to be elsewhere)" }, { "identity": "w5", "map": "class" } ] }, { "id": "ProcedureRequest.priority", "path": "ProcedureRequest.priority", "short": "routine | urgent | asap | stat", "definition": "Indicates how quickly the ProcedureRequest should be addressed with respect to other requests.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "meaningWhenMissing": "If missing, this task should be performed with normal priority", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestPriority" } ], "strength": "required", "description": "Identifies the level of importance to be assigned to actioning the request", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/request-priority" } }, "mapping": [ { "identity": "workflow", "map": "Request.priority" }, { "identity": "v2", "map": "TQ1.9" }, { "identity": "rim", "map": ".priorityCode" }, { "identity": "w5", "map": "class" } ] }, { "id": "ProcedureRequest.doNotPerform", "path": "ProcedureRequest.doNotPerform", "short": "True if procedure should not be performed", "definition": "Set this to true if the record is saying that the procedure should NOT be performed.", "comment": "This element is labeled as a [modifier](conformance-rules.html#isModifier.html) because it indicates that a procedure shouldn't happen, instead of a request for it to happen. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ProcedureRequest.code and ProcedureRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.", "requirements": "Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "defaultValueBoolean": false, "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": ".actionNegationInd" } ] }, { "id": "ProcedureRequest.category", "path": "ProcedureRequest.category", "short": "Classification of procedure", "definition": "A code that classifies the procedure for searching, sorting and display purposes (e.g. \"Surgical Procedure\").", "comment": "There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set.", "requirements": "Used for filtering what procedure request are retrieved and displayed.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestCategory" } ], "strength": "example", "description": "Classification of the procedure", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-category" } }, "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"INT\"].code" }, { "identity": "w5", "map": "class" } ] }, { "id": "ProcedureRequest.code", "path": "ProcedureRequest.code", "short": "What is being requested/ordered", "definition": "A code that identifies a particular procedure, diagnostic investigation, or panel of investigations, that have been requested.", "comment": "Many laboratory and radiology procedure codes embed the specimen/organ system in the test ordeer name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestCode" } ], "strength": "example", "description": "Codes for tests/services that can be performed by procedure or diagnostic services. For laboratory, LOINC is (preferred)[http://hl7.org/fhir/STU3/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html).", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-code" } }, "mapping": [ { "identity": "workflow", "map": "Request.code" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".code" }, { "identity": "quick", "map": "Procedure.procedureCode" }, { "identity": "w5", "map": "what" } ] }, { "id": "ProcedureRequest.subject", "path": "ProcedureRequest.subject", "short": "Individual the service is ordered for", "definition": "On whom or what the procedure or diagnostic is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans).", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Group" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Location" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Device" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.subject" }, { "identity": "v2", "map": "Accompanying PID segment" }, { "identity": "rim", "map": ".participation[typeCode=SBJ].role" }, { "identity": "quick", "map": "ClinicalStatement.subject" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "ProcedureRequest.context", "path": "ProcedureRequest.context", "short": "Encounter or Episode during which request was created", "definition": "An encounter or episode of care that provides additional information about the healthcare context in which this request is made.", "alias": [ "encounter" ], "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.context" }, { "identity": "v2", "map": "Accompanying PV1" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=COMP].source[classCode<=PCPR, moodCode=EVN]" }, { "identity": "quick", "map": "ClinicalStatement.encounter" }, { "identity": "w5", "map": "context" } ] }, { "id": "ProcedureRequest.occurrence[x]", "path": "ProcedureRequest.occurrence[x]", "short": "When procedure should occur", "definition": "The date/time at which the diagnostic testing should occur.", "alias": [ "schedule" ], "min": 0, "max": "1", "type": [ { "code": "dateTime" }, { "code": "Period" }, { "code": "Timing" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.occurrence[x]" }, { "identity": "v2", "map": "Accompanying TQ1/TQ2 segments" }, { "identity": "rim", "map": ".effectiveTime" }, { "identity": "quick", "map": "Procedure.procedureSchedule" }, { "identity": "w5", "map": "when.planned" } ] }, { "id": "ProcedureRequest.asNeeded[x]", "path": "ProcedureRequest.asNeeded[x]", "short": "Preconditions for procedure or diagnostic", "definition": "If a CodeableConcept is present, it indicates the pre-condition for performing the procedure. For example \"pain\", \"on flare-up\", etc.", "min": 0, "max": "1", "type": [ { "code": "boolean" }, { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureAsNeededReason" } ], "strength": "example", "description": "A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example \"pain\", \"on flare-up\", etc.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/medication-as-needed-reason" } }, "mapping": [ { "identity": "rim", "map": "boolean: precondition.negationInd (inversed - so negationInd = true means asNeeded=false CodeableConcept: precondition.observationEventCriterion[code=\"Assertion\"].value" }, { "identity": "quick", "map": "Proposal.prnReason.reason" } ] }, { "id": "ProcedureRequest.authoredOn", "path": "ProcedureRequest.authoredOn", "short": "Date request signed", "definition": "When the request transitioned to being actionable.", "alias": [ "orderedOn" ], "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.authoredOn" }, { "identity": "v2", "map": "ORC.9" }, { "identity": "rim", "map": ".participation[typeCode=AUT].time" }, { "identity": "quick", "map": "Proposal.proposedAtTime" }, { "identity": "w5", "map": "when.recorded" } ] }, { "id": "ProcedureRequest.requester", "path": "ProcedureRequest.requester", "short": "Who/what is requesting procedure or diagnostic", "definition": "The individual who initiated the request and has responsibility for its activation.", "comment": "This not the dispatcher, but rather who is the authorizer.", "alias": [ "author", "orderer" ], "min": 0, "max": "1", "type": [ { "code": "BackboneElement" } ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() | (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "Element" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.requester" }, { "identity": "v2", "map": "ORC.12" }, { "identity": "rim", "map": ".participation[typeCode=AUT].role" }, { "identity": "quick", "map": "ClinicalStatement.statementAuthor" } ] }, { "id": "ProcedureRequest.requester.id", "path": "ProcedureRequest.requester.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ProcedureRequest.requester.extension", "path": "ProcedureRequest.requester.extension", "short": "Additional Content defined by implementations", "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.", "comment": "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.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "ProcedureRequest.requester.modifierExtension", "path": "ProcedureRequest.requester.modifierExtension", "short": "Extensions that cannot be ignored", "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.", "comment": "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.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "ProcedureRequest.requester.agent", "path": "ProcedureRequest.requester.agent", "short": "Individual making the request", "definition": "The device, practitioner or organization who initiated the request.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.requester.agent" }, { "identity": "v2", "map": "ORC.12" }, { "identity": "rim", "map": ".player" }, { "identity": "quick", "map": "ClinicalStatement.statementAuthor" }, { "identity": "w5", "map": "who.author" } ] }, { "id": "ProcedureRequest.requester.onBehalfOf", "path": "ProcedureRequest.requester.onBehalfOf", "short": "Organization agent is acting for", "definition": "The organization the device or practitioner was acting on behalf of.", "requirements": "Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when authoring the request.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.requester.onBehalfOf" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".scoper" } ] }, { "id": "ProcedureRequest.performerType", "path": "ProcedureRequest.performerType", "short": "Performer role", "definition": "Desired type of performer for doing the diagnostic testing.", "comment": "this is a role, not a participation type. I.e. does not describe the task, but describes the capacity. For example, “compounding pharmacy” or “psychiatrist” or “internal referral”.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestParticipantRole" } ], "strength": "example", "description": "Indicates specific responsibility of an individual within the care team, such as \"Primary physician\", \"Team coordinator\", \"Caregiver\", etc.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/participant-role" } }, "mapping": [ { "identity": "workflow", "map": "Request.performerType" }, { "identity": "v2", "map": "PRT" }, { "identity": "rim", "map": ".participation[typeCode=PRF].role[scoper.determinerCode=KIND].code" }, { "identity": "w5", "map": "who.actor" } ] }, { "id": "ProcedureRequest.performer", "path": "ProcedureRequest.performer", "short": "Requested perfomer", "definition": "The desired perfomer for doing the diagnostic testing. For example, the surgeon, dermatopathologist, endoscopist, etc.", "comment": "If needed, use an [extension](extensibility.html) for listing alternative performers and/or roles and/or preference.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/HealthcareService" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.Performer" }, { "identity": "v2", "map": "PRT" }, { "identity": "rim", "map": ".participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]" }, { "identity": "w5", "map": "who.actor" } ] }, { "id": "ProcedureRequest.reasonCode", "path": "ProcedureRequest.reasonCode", "short": "Explanation/Justification for test", "definition": "An explanation or justification for why this diagnostic investigation is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in supportingInformation.", "comment": "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example](procedurerequest-example-di.html).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestReason" } ], "strength": "example", "description": "Diagnosis or problem codes justifying the reason for requesting the procedure or diagnostic investigation.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-reason" } }, "mapping": [ { "identity": "workflow", "map": "Request.reasonCod" }, { "identity": "v2", "map": "ORC.16" }, { "identity": "rim", "map": ".reasonCode" }, { "identity": "w5", "map": "why" } ] }, { "id": "ProcedureRequest.reasonReference", "path": "ProcedureRequest.reasonReference", "short": "Explanation/Justification for test", "definition": "Indicates another resource that provides a justification for why this diagnostic investigation is being requested. May relate to the resources referred to in supportingInformation.", "comment": "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example](procedurerequest-example-di.html).", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.reasonReference" }, { "identity": "v2", "map": "ORC.16" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RSON].target" }, { "identity": "w5", "map": "why" } ] }, { "id": "ProcedureRequest.supportingInfo", "path": "ProcedureRequest.supportingInfo", "short": "Additional clinical information", "definition": "Additional clinical information about the patient or specimen that may influence the procedure or diagnostics or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as \"ask at order entry questions (AOEs)\". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements.", "alias": [ "Ask at order entry question", "AOE" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "mapping": [ { "identity": "workflow", "map": "Request.supportingInformation" }, { "identity": "v2", "map": "Accompanying segments" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=PERT].target" } ] }, { "id": "ProcedureRequest.specimen", "path": "ProcedureRequest.specimen", "short": "Procedure Samples", "definition": "One or more specimens that the laboratory procedure will use.", "comment": "Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, If the request is entered first with an unknown specimen, The [Specimen](specimen.html) resource references to the ProcedureRequest.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Specimen" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": ".participation[typeCode=SPC].role" } ] }, { "id": "ProcedureRequest.bodySite", "path": "ProcedureRequest.bodySite", "short": "Location on Body", "definition": "Anatomic location where the procedure should be performed. This is the target site.", "comment": "Only used if not implicit in the code found in ProcedureRequest.type. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension [procedurerequest-targetBodySite](extension-procedurerequest-targetbodysite.html).", "requirements": "Knowing where the procedure is performed is important for tracking if multiple sites are possible.", "alias": [ "location" ], "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BodySite" } ], "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/body-site" } }, "mapping": [ { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": "targetSiteCode" }, { "identity": "quick", "map": "Procedure.targetBodySite" } ] }, { "id": "ProcedureRequest.note", "path": "ProcedureRequest.note", "short": "Comments", "definition": "Any other notes and comments made about the service request. For example, letting provider know that \"patient hates needles\" or other provider instructions.", "min": 0, "max": "*", "type": [ { "code": "Annotation" } ], "mapping": [ { "identity": "workflow", "map": "Request.note" }, { "identity": "v2", "map": "NTE" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=SUBJ].source[classCode=ANNGEN, moodCode=EVN].value[xsi:type=ST]" }, { "identity": "quick", "map": "ClinicalStatement.additionalText" } ] }, { "id": "ProcedureRequest.relevantHistory", "path": "ProcedureRequest.relevantHistory", "short": "Request provenance", "definition": "Key events in the history of the request.", "comment": "This may not include provenances for all versions of the request – only those deemed “relevant” or important.\rThis SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude\rAll Provenances should have some historical version of this Request as their subject.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Provenance" } ], "mapping": [ { "identity": "workflow", "map": "Request.relevantHistory" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]" } ] } ] }, "differential": { "element": [ { "id": "ProcedureRequest", "path": "ProcedureRequest", "short": "A request for a procedure or diagnostic to be performed", "definition": "A record of a request for diagnostic investigations, treatments, or operations to be performed.", "alias": [ "diagnostic request" ], "min": 0, "max": "*", "mapping": [ { "identity": "workflow", "map": "Request" }, { "identity": "v2", "map": "ORC" }, { "identity": "rim", "map": "Act[moodCode<=INT]" }, { "identity": "w5", "map": "clinical.general" } ] }, { "id": "ProcedureRequest.identifier", "path": "ProcedureRequest.identifier", "short": "Identifiers assigned to this order", "definition": "Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller.", "comment": "The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.identifier" }, { "identity": "v2", "map": "ORC.2, ORC.3" }, { "identity": "rim", "map": ".identifier" }, { "identity": "quick", "map": "ClinicalStatement.identifier" }, { "identity": "w5", "map": "id" } ] }, { "id": "ProcedureRequest.definition", "path": "ProcedureRequest.definition", "short": "Protocol or definition", "definition": "Protocol or definition followed by this request.", "alias": [ "protocol" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/ActivityDefinition" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/PlanDefinition" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.definition" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=DEFN].target" } ] }, { "id": "ProcedureRequest.basedOn", "path": "ProcedureRequest.basedOn", "short": "What request fulfills", "definition": "Plan/proposal/order fulfilled by this request.", "alias": [ "fulfills" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.basedOn" }, { "identity": "v2", "map": "ORC.8 (plus others)" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=FLFS].target" } ] }, { "id": "ProcedureRequest.replaces", "path": "ProcedureRequest.replaces", "short": "What request replaces", "definition": "The request takes the place of the referenced completed or terminated request(s).", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.replaces" }, { "identity": "v2", "map": "Handled by message location of ORC (ORC.1=RO or RU)" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RPLC].target" } ] }, { "id": "ProcedureRequest.requisition", "path": "ProcedureRequest.requisition", "short": "Composite Request ID", "definition": "A shared identifier common to all procedure or diagnostic requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier.", "comment": "Requests are linked either by a \"basedOn\" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.", "requirements": "Some business processes need to know if multiple items were ordered as part of the same \"requisition\" for billing or other purposes.", "alias": [ "grouperId", "groupIdentifier" ], "min": 0, "max": "1", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ORC.4" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=COMP].source[moodCode=INT].identifier" } ] }, { "id": "ProcedureRequest.status", "path": "ProcedureRequest.status", "short": "draft | active | suspended | completed | entered-in-error | cancelled", "definition": "The status of the order.", "comment": "The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see [Event Pattern](event.html) for general discussion) or using the [Task](task.html) resource.\n\nThis element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestStatus" } ], "strength": "required", "description": "The status of a procedure or diagnostic order.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/request-status" } }, "mapping": [ { "identity": "workflow", "map": "Request.status" }, { "identity": "v2", "map": "ORC.5" }, { "identity": "rim", "map": ".status" }, { "identity": "quick", "map": "Action.currentStatus" }, { "identity": "w5", "map": "status" } ] }, { "id": "ProcedureRequest.intent", "path": "ProcedureRequest.intent", "short": "proposal | plan | order +", "definition": "Whether the request is a proposal, plan, an original order or a reflex order.", "comment": "This element is labeled as a modifier because the intent alters when and how the resource is actually applicable.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestIntent" } ], "strength": "required", "description": "The kind of procedure or diagnostic request", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/request-intent" } }, "mapping": [ { "identity": "workflow", "map": "Request.intent" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".moodCode (nuances beyond PRP/PLAN/RQO would need to be elsewhere)" }, { "identity": "w5", "map": "class" } ] }, { "id": "ProcedureRequest.priority", "path": "ProcedureRequest.priority", "short": "routine | urgent | asap | stat", "definition": "Indicates how quickly the ProcedureRequest should be addressed with respect to other requests.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "meaningWhenMissing": "If missing, this task should be performed with normal priority", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestPriority" } ], "strength": "required", "description": "Identifies the level of importance to be assigned to actioning the request", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/request-priority" } }, "mapping": [ { "identity": "workflow", "map": "Request.priority" }, { "identity": "v2", "map": "TQ1.9" }, { "identity": "rim", "map": ".priorityCode" }, { "identity": "w5", "map": "class" } ] }, { "id": "ProcedureRequest.doNotPerform", "path": "ProcedureRequest.doNotPerform", "short": "True if procedure should not be performed", "definition": "Set this to true if the record is saying that the procedure should NOT be performed.", "comment": "This element is labeled as a [modifier](conformance-rules.html#isModifier.html) because it indicates that a procedure shouldn't happen, instead of a request for it to happen. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ProcedureRequest.code and ProcedureRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.", "requirements": "Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "defaultValueBoolean": false, "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": ".actionNegationInd" } ] }, { "id": "ProcedureRequest.category", "path": "ProcedureRequest.category", "short": "Classification of procedure", "definition": "A code that classifies the procedure for searching, sorting and display purposes (e.g. \"Surgical Procedure\").", "comment": "There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set.", "requirements": "Used for filtering what procedure request are retrieved and displayed.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestCategory" } ], "strength": "example", "description": "Classification of the procedure", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-category" } }, "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"INT\"].code" }, { "identity": "w5", "map": "class" } ] }, { "id": "ProcedureRequest.code", "path": "ProcedureRequest.code", "short": "What is being requested/ordered", "definition": "A code that identifies a particular procedure, diagnostic investigation, or panel of investigations, that have been requested.", "comment": "Many laboratory and radiology procedure codes embed the specimen/organ system in the test ordeer name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestCode" } ], "strength": "example", "description": "Codes for tests/services that can be performed by procedure or diagnostic services. For laboratory, LOINC is (preferred)[http://hl7.org/fhir/STU3/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html).", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-code" } }, "mapping": [ { "identity": "workflow", "map": "Request.code" }, { "identity": "v2", "map": "Varies by domain" }, { "identity": "rim", "map": ".code" }, { "identity": "quick", "map": "Procedure.procedureCode" }, { "identity": "w5", "map": "what" } ] }, { "id": "ProcedureRequest.subject", "path": "ProcedureRequest.subject", "short": "Individual the service is ordered for", "definition": "On whom or what the procedure or diagnostic is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans).", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Group" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Location" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Device" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.subject" }, { "identity": "v2", "map": "Accompanying PID segment" }, { "identity": "rim", "map": ".participation[typeCode=SBJ].role" }, { "identity": "quick", "map": "ClinicalStatement.subject" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "ProcedureRequest.context", "path": "ProcedureRequest.context", "short": "Encounter or Episode during which request was created", "definition": "An encounter or episode of care that provides additional information about the healthcare context in which this request is made.", "alias": [ "encounter" ], "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Encounter" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.context" }, { "identity": "v2", "map": "Accompanying PV1" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=COMP].source[classCode<=PCPR, moodCode=EVN]" }, { "identity": "quick", "map": "ClinicalStatement.encounter" }, { "identity": "w5", "map": "context" } ] }, { "id": "ProcedureRequest.occurrence[x]", "path": "ProcedureRequest.occurrence[x]", "short": "When procedure should occur", "definition": "The date/time at which the diagnostic testing should occur.", "alias": [ "schedule" ], "min": 0, "max": "1", "type": [ { "code": "dateTime" }, { "code": "Period" }, { "code": "Timing" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.occurrence[x]" }, { "identity": "v2", "map": "Accompanying TQ1/TQ2 segments" }, { "identity": "rim", "map": ".effectiveTime" }, { "identity": "quick", "map": "Procedure.procedureSchedule" }, { "identity": "w5", "map": "when.planned" } ] }, { "id": "ProcedureRequest.asNeeded[x]", "path": "ProcedureRequest.asNeeded[x]", "short": "Preconditions for procedure or diagnostic", "definition": "If a CodeableConcept is present, it indicates the pre-condition for performing the procedure. For example \"pain\", \"on flare-up\", etc.", "min": 0, "max": "1", "type": [ { "code": "boolean" }, { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureAsNeededReason" } ], "strength": "example", "description": "A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example \"pain\", \"on flare-up\", etc.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/medication-as-needed-reason" } }, "mapping": [ { "identity": "rim", "map": "boolean: precondition.negationInd (inversed - so negationInd = true means asNeeded=false CodeableConcept: precondition.observationEventCriterion[code=\"Assertion\"].value" }, { "identity": "quick", "map": "Proposal.prnReason.reason" } ] }, { "id": "ProcedureRequest.authoredOn", "path": "ProcedureRequest.authoredOn", "short": "Date request signed", "definition": "When the request transitioned to being actionable.", "alias": [ "orderedOn" ], "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.authoredOn" }, { "identity": "v2", "map": "ORC.9" }, { "identity": "rim", "map": ".participation[typeCode=AUT].time" }, { "identity": "quick", "map": "Proposal.proposedAtTime" }, { "identity": "w5", "map": "when.recorded" } ] }, { "id": "ProcedureRequest.requester", "path": "ProcedureRequest.requester", "short": "Who/what is requesting procedure or diagnostic", "definition": "The individual who initiated the request and has responsibility for its activation.", "comment": "This not the dispatcher, but rather who is the authorizer.", "alias": [ "author", "orderer" ], "min": 0, "max": "1", "type": [ { "code": "BackboneElement" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.requester" }, { "identity": "v2", "map": "ORC.12" }, { "identity": "rim", "map": ".participation[typeCode=AUT].role" }, { "identity": "quick", "map": "ClinicalStatement.statementAuthor" } ] }, { "id": "ProcedureRequest.requester.agent", "path": "ProcedureRequest.requester.agent", "short": "Individual making the request", "definition": "The device, practitioner or organization who initiated the request.", "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.requester.agent" }, { "identity": "v2", "map": "ORC.12" }, { "identity": "rim", "map": ".player" }, { "identity": "quick", "map": "ClinicalStatement.statementAuthor" }, { "identity": "w5", "map": "who.author" } ] }, { "id": "ProcedureRequest.requester.onBehalfOf", "path": "ProcedureRequest.requester.onBehalfOf", "short": "Organization agent is acting for", "definition": "The organization the device or practitioner was acting on behalf of.", "requirements": "Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when authoring the request.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.requester.onBehalfOf" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".scoper" } ] }, { "id": "ProcedureRequest.performerType", "path": "ProcedureRequest.performerType", "short": "Performer role", "definition": "Desired type of performer for doing the diagnostic testing.", "comment": "this is a role, not a participation type. I.e. does not describe the task, but describes the capacity. For example, “compounding pharmacy” or “psychiatrist” or “internal referral”.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestParticipantRole" } ], "strength": "example", "description": "Indicates specific responsibility of an individual within the care team, such as \"Primary physician\", \"Team coordinator\", \"Caregiver\", etc.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/participant-role" } }, "mapping": [ { "identity": "workflow", "map": "Request.performerType" }, { "identity": "v2", "map": "PRT" }, { "identity": "rim", "map": ".participation[typeCode=PRF].role[scoper.determinerCode=KIND].code" }, { "identity": "w5", "map": "who.actor" } ] }, { "id": "ProcedureRequest.performer", "path": "ProcedureRequest.performer", "short": "Requested perfomer", "definition": "The desired perfomer for doing the diagnostic testing. For example, the surgeon, dermatopathologist, endoscopist, etc.", "comment": "If needed, use an [extension](extensibility.html) for listing alternative performers and/or roles and/or preference.", "min": 0, "max": "1", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/HealthcareService" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.Performer" }, { "identity": "v2", "map": "PRT" }, { "identity": "rim", "map": ".participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]" }, { "identity": "w5", "map": "who.actor" } ] }, { "id": "ProcedureRequest.reasonCode", "path": "ProcedureRequest.reasonCode", "short": "Explanation/Justification for test", "definition": "An explanation or justification for why this diagnostic investigation is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in supportingInformation.", "comment": "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example](procedurerequest-example-di.html).", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ProcedureRequestReason" } ], "strength": "example", "description": "Diagnosis or problem codes justifying the reason for requesting the procedure or diagnostic investigation.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-reason" } }, "mapping": [ { "identity": "workflow", "map": "Request.reasonCod" }, { "identity": "v2", "map": "ORC.16" }, { "identity": "rim", "map": ".reasonCode" }, { "identity": "w5", "map": "why" } ] }, { "id": "ProcedureRequest.reasonReference", "path": "ProcedureRequest.reasonReference", "short": "Explanation/Justification for test", "definition": "Indicates another resource that provides a justification for why this diagnostic investigation is being requested. May relate to the resources referred to in supportingInformation.", "comment": "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example](procedurerequest-example-di.html).", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation" } ], "isSummary": true, "mapping": [ { "identity": "workflow", "map": "Request.reasonReference" }, { "identity": "v2", "map": "ORC.16" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=RSON].target" }, { "identity": "w5", "map": "why" } ] }, { "id": "ProcedureRequest.supportingInfo", "path": "ProcedureRequest.supportingInfo", "short": "Additional clinical information", "definition": "Additional clinical information about the patient or specimen that may influence the procedure or diagnostics or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as \"ask at order entry questions (AOEs)\". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements.", "alias": [ "Ask at order entry question", "AOE" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Resource" } ], "mapping": [ { "identity": "workflow", "map": "Request.supportingInformation" }, { "identity": "v2", "map": "Accompanying segments" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=PERT].target" } ] }, { "id": "ProcedureRequest.specimen", "path": "ProcedureRequest.specimen", "short": "Procedure Samples", "definition": "One or more specimens that the laboratory procedure will use.", "comment": "Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, If the request is entered first with an unknown specimen, The [Specimen](specimen.html) resource references to the ProcedureRequest.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Specimen" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": ".participation[typeCode=SPC].role" } ] }, { "id": "ProcedureRequest.bodySite", "path": "ProcedureRequest.bodySite", "short": "Location on Body", "definition": "Anatomic location where the procedure should be performed. This is the target site.", "comment": "Only used if not implicit in the code found in ProcedureRequest.type. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension [procedurerequest-targetBodySite](extension-procedurerequest-targetbodysite.html).", "requirements": "Knowing where the procedure is performed is important for tracking if multiple sites are possible.", "alias": [ "location" ], "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "BodySite" } ], "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/body-site" } }, "mapping": [ { "identity": "v2", "map": "SPM" }, { "identity": "rim", "map": "targetSiteCode" }, { "identity": "quick", "map": "Procedure.targetBodySite" } ] }, { "id": "ProcedureRequest.note", "path": "ProcedureRequest.note", "short": "Comments", "definition": "Any other notes and comments made about the service request. For example, letting provider know that \"patient hates needles\" or other provider instructions.", "min": 0, "max": "*", "type": [ { "code": "Annotation" } ], "mapping": [ { "identity": "workflow", "map": "Request.note" }, { "identity": "v2", "map": "NTE" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=SUBJ].source[classCode=ANNGEN, moodCode=EVN].value[xsi:type=ST]" }, { "identity": "quick", "map": "ClinicalStatement.additionalText" } ] }, { "id": "ProcedureRequest.relevantHistory", "path": "ProcedureRequest.relevantHistory", "short": "Request provenance", "definition": "Key events in the history of the request.", "comment": "This may not include provenances for all versions of the request – only those deemed “relevant” or important.\rThis SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude\rAll Provenances should have some historical version of this Request as their subject.", "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Provenance" } ], "mapping": [ { "identity": "workflow", "map": "Request.relevantHistory" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": ".inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]" } ] } ] } }