Vital Records Birth and Fetal Death Reporting
0.1.0 - STU 1 Ballot
Vital Records Birth and Fetal Death Reporting
0.1.0 - STU 1 Ballot
This page is part of the Vital Records Birth and Fetal Death Reporting (v0.1.0: STU 1 on FHIR R4 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
| Defining URL: | http://hl7.org/fhir/us/bfdr/StructureDefinition/Procedure-obstetric |
| Version: | 0.1.0 |
| Name: | ProcedureObstetric |
| Title: | Procedure - Obstetric |
| Status: | Draft as of 2020-06-30T00:00:00.000Z |
| Definition: | This profile represents information about a particular medical treatment or invasive/manipulative procedure that was performed during this pregnancy specifically in the treatment of the pregnancy, management of labor and/or delivery. |
| Publisher: | HL7 International - Public Health Work Group |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/bfdr/StructureDefinition/Procedure-obstetric
This concept is mapped to:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | |
  code | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Obstetric Procedures (NCHS) (required) | |
 subject | 1..1 | Reference(Patient - Mother) | Who the procedure was performed on | |
 outcome | S | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: ProcedureOutcomeCodes(SNOMEDCT) (required) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition |
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event |
| status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| code | SΣ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Obstetric Procedures (NCHS) (required) |
| subject | SΣ | 1..1 | Reference(Patient - Mother) | Who the procedure was performed on |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
  performed[x] | SΣ | 1..1 | When the procedure was performed | |
 performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure |
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure |
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. |
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| outcome | SΣ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: ProcedureOutcomeCodes(SNOMEDCT) (required) |
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |
| manipulated | 1..1 | Reference(Device) | Device that was changed | |
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | |
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| code | Σ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Obstetric Procedures (NCHS) (required) |
| subject | Σ | 1..1 | Reference(Patient - Mother) | Who the procedure was performed on |
| performed[x] | Σ | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| outcome | Σ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: ProcedureOutcomeCodes(SNOMEDCT) (required) |
| Documentation for this format | ||||
This structure is derived from USCoreProcedureProfile
Differential View
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | |
| code | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Obstetric Procedures (NCHS) (required) | |
| subject | 1..1 | Reference(Patient - Mother) | Who the procedure was performed on | |
| outcome | S | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: ProcedureOutcomeCodes(SNOMEDCT) (required) |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient | |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition |
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event |
| status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| code | SΣ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Obstetric Procedures (NCHS) (required) |
| subject | SΣ | 1..1 | Reference(Patient - Mother) | Who the procedure was performed on |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | SΣ | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure |
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure |
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. |
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| outcome | SΣ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: ProcedureOutcomeCodes(SNOMEDCT) (required) |
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |
| manipulated | 1..1 | Reference(Device) | Device that was changed | |
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet |
| Procedure.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Procedure.status | required | EventStatus |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) |
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) |
| Procedure.code | required | PHVS_ObstetricProcedures_NCHS |
| Procedure.performer.function | example | ProcedurePerformerRoleCodes |
| Procedure.reasonCode | example | ProcedureReasonCodes |
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| Procedure.outcome | required | ProcedureOutcomeCodes(SNOMEDCT) |
| Procedure.complication | example | Condition/Problem/DiagnosisCodes |
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) |
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes |
| Procedure.usedCode | example | FHIRDeviceTypes |
| Id | Path | Details | Requirements |
| dom-2 | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | Procedure.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.instantiatesCanonical | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.instantiatesUri | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.partOf | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.statusReason | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.performed[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.recorder | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.asserter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.performer.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.performer.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.performer.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.performer.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.performer.function | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.performer.actor | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.performer.onBehalfOf | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.location | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.reasonCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.reasonReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.bodySite | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.outcome | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.report | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.complication | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.complicationDetail | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.followUp | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.note | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.focalDevice | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.focalDevice.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.focalDevice.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.focalDevice.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.focalDevice.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.focalDevice.action | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.focalDevice.manipulated | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.usedReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.usedCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2020+ HL7 International - Public Health Work Group. Package hl7.fhir.us.bfdr#0.1.0 based on FHIR 4.0.1. Generated 2020-12-16
Links: Table of Contents |
QA Report
| Version History |
Search |
|
Propose a change