Breast Radiology Reporting - 1st for comment ballot

This page is part of the Breast Radiology Report (v0.1.0: Comment Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Procedure

 

The official URL for this profile is: 

http://hl7.org/fhir/us/breast-radiology/StructureDefinition/obf-Procedure

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

This profile builds on USCoreProcedureProfile.

This profile was published on Fri Aug 02 00:00:00 EDT 2019 as a active by Hl7 - Clinical Interoperability Council.

Summary

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

obf.Procedure maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.source
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  ProcedureBasedOn maps to basedOn
  ProcedurePartOf maps to partOf  // add Observation, MedicationAdministration
  Status maps to status
  StatusReason maps to statusReason
  Category maps to category
  Code maps to code
  SubjectOfRecord maps to subject
  CareContext maps to encounter
  OccurrenceTimeOrPeriod maps to performed[x]
  PersonAuthor maps to recorder
  PersonInformationSource maps to asserter
  Participation maps to performer
  Participation.Participant maps to performer.actor  // Added Target Type PractitionerRole -- not implemented
  Participation.ParticipationType maps to performer.function  // renamed role to function in R4
  Participation.OnBehalfOf maps to performer.onBehalfOf
  Location maps to location
  ReasonCode maps to reasonCode
  ProcedureReasonReference maps to reasonReference
  BodyLocation.Code maps to bodySite
  BodyLocation.Laterality maps to bodySite.extension
  BodyLocation.AnatomicalOrientation maps to bodySite.extension
  BodyLocation.RelationToLandmark maps to bodySite.extension
  Annotation maps to note
  Outcome maps to outcome
  DiagnosticReport maps to report
  ComplicationCode maps to complication
  ComplicationReference maps to complicationDetail
  FollowUp maps to followUp
  FocalDevice maps to focalDevice
  FocalDevice.Device maps to focalDevice.manipulated
  FocalDevice.FocalDeviceAction maps to focalDevice.action
  MaterialUsedReference maps to usedReference
  UsedCode maps to usedCode
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure obf-Procedure
... extension Slice: Unordered, Open by value:url
... statementdatetime 0..1StatementDateTime
... treatmentintent 0..1TreatmentIntent
... basedOn 0..1Reference(ServiceRequest)
... partOf 0..1Reference(obf-Procedure | MedicationAdministration | obf-Observation)
... encounter Reference(US Core Encounter Profile)
... recorder Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)A human author, patient, practitioner, or related person, as opposed to an organization or device
... asserter Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)The person who provided the information, not necessarily the patient
... performer
.... actor Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | RelatedPerson | US Core Device Profile)Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3
.... onBehalfOf Reference(US Core Organization Profile)
... location Reference(US Core Location Profile)
... reasonCode 0..1
... reasonReference 0..1Reference(obf-Condition | obf-Observation | obf-Procedure | obf-DiagnosticReport | US Core DocumentReference Profile)
... bodySite Binding: BodyLocationVS (preferred)
.... laterality 0..*Laterality
.... anatomicalorientation 0..*AnatomicalOrientation
.... relationtolandmark 0..*RelationToLandmark
... report Reference(obf-DiagnosticReport)
... complicationDetail Reference(obf-Condition)
... focalDevice
.... action Binding: ProcedureDeviceActionCodes (required)
.... manipulated Reference(US Core Device Profile)
... usedReference Reference(US Core Device Profile | US Core Medication Profile | Substance)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*obf-Procedure
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... statementdatetime 0..1StatementDateTime
... treatmentintent 0..1TreatmentIntent
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..1Reference(ServiceRequest)A request for this procedure
... partOf Σ0..1Reference(obf-Procedure | MedicationAdministration | obf-Observation)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown
Binding: EventStatus (required)
... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example)
... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example)
... code SΣ1..1CodeableConceptSNOMED-CT | ICD-10 | CPT-4
Binding: US Core Procedure Codes (extensible)
Max Binding: US Core Procedure Codes
... subject SΣ1..1Reference(US Core Patient Profile)Who the procedure was performed on
... encounter Σ0..1Reference(US Core Encounter Profile)Encounter created as part of
... performed[x] SΣ1..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
... recorder Σ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)A human author, patient, practitioner, or related person, as opposed to an organization or device
... asserter Σ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)The person who provided the information, not necessarily the patient
... performer ΣI0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example)
.... actor Σ1..1Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | RelatedPerson | US Core Device Profile)Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3
.... onBehalfOf 0..1Reference(US Core Organization Profile)Organization the device or practitioner was acting for
... location Σ0..1Reference(US Core Location Profile)Where the procedure happened
... reasonCode Σ0..1CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example)
... reasonReference Σ0..1Reference(obf-Condition | obf-Observation | obf-Procedure | obf-DiagnosticReport | US Core DocumentReference Profile)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: BodyLocationVS (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... laterality 0..*Laterality
.... anatomicalorientation 0..*AnatomicalOrientation
.... relationtolandmark 0..*RelationToLandmark
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example)
... report 0..*Reference(obf-DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example)
... complicationDetail 0..*Reference(obf-Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example)
... note 0..*AnnotationAdditional information about the procedure
... focalDevice I0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (required)
.... manipulated 1..1Reference(US Core Device Profile)Device that was changed
... usedReference 0..*Reference(US Core Device Profile | US Core Medication Profile | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example)

doco Documentation for this format

Summary

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

obf.Procedure maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.source
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  ProcedureBasedOn maps to basedOn
  ProcedurePartOf maps to partOf  // add Observation, MedicationAdministration
  Status maps to status
  StatusReason maps to statusReason
  Category maps to category
  Code maps to code
  SubjectOfRecord maps to subject
  CareContext maps to encounter
  OccurrenceTimeOrPeriod maps to performed[x]
  PersonAuthor maps to recorder
  PersonInformationSource maps to asserter
  Participation maps to performer
  Participation.Participant maps to performer.actor  // Added Target Type PractitionerRole -- not implemented
  Participation.ParticipationType maps to performer.function  // renamed role to function in R4
  Participation.OnBehalfOf maps to performer.onBehalfOf
  Location maps to location
  ReasonCode maps to reasonCode
  ProcedureReasonReference maps to reasonReference
  BodyLocation.Code maps to bodySite
  BodyLocation.Laterality maps to bodySite.extension
  BodyLocation.AnatomicalOrientation maps to bodySite.extension
  BodyLocation.RelationToLandmark maps to bodySite.extension
  Annotation maps to note
  Outcome maps to outcome
  DiagnosticReport maps to report
  ComplicationCode maps to complication
  ComplicationReference maps to complicationDetail
  FollowUp maps to followUp
  FocalDevice maps to focalDevice
  FocalDevice.Device maps to focalDevice.manipulated
  FocalDevice.FocalDeviceAction maps to focalDevice.action
  MaterialUsedReference maps to usedReference
  UsedCode maps to usedCode

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure obf-Procedure
... extension Slice: Unordered, Open by value:url
... statementdatetime 0..1StatementDateTime
... treatmentintent 0..1TreatmentIntent
... basedOn 0..1Reference(ServiceRequest)
... partOf 0..1Reference(obf-Procedure | MedicationAdministration | obf-Observation)
... encounter Reference(US Core Encounter Profile)
... recorder Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)A human author, patient, practitioner, or related person, as opposed to an organization or device
... asserter Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)The person who provided the information, not necessarily the patient
... performer
.... actor Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | RelatedPerson | US Core Device Profile)Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3
.... onBehalfOf Reference(US Core Organization Profile)
... location Reference(US Core Location Profile)
... reasonCode 0..1
... reasonReference 0..1Reference(obf-Condition | obf-Observation | obf-Procedure | obf-DiagnosticReport | US Core DocumentReference Profile)
... bodySite Binding: BodyLocationVS (preferred)
.... laterality 0..*Laterality
.... anatomicalorientation 0..*AnatomicalOrientation
.... relationtolandmark 0..*RelationToLandmark
... report Reference(obf-DiagnosticReport)
... complicationDetail Reference(obf-Condition)
... focalDevice
.... action Binding: ProcedureDeviceActionCodes (required)
.... manipulated Reference(US Core Device Profile)
... usedReference Reference(US Core Device Profile | US Core Medication Profile | Substance)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*obf-Procedure
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... statementdatetime 0..1StatementDateTime
... treatmentintent 0..1TreatmentIntent
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..1Reference(ServiceRequest)A request for this procedure
... partOf Σ0..1Reference(obf-Procedure | MedicationAdministration | obf-Observation)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown
Binding: EventStatus (required)
... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example)
... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example)
... code SΣ1..1CodeableConceptSNOMED-CT | ICD-10 | CPT-4
Binding: US Core Procedure Codes (extensible)
Max Binding: US Core Procedure Codes
... subject SΣ1..1Reference(US Core Patient Profile)Who the procedure was performed on
... encounter Σ0..1Reference(US Core Encounter Profile)Encounter created as part of
... performed[x] SΣ1..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
... recorder Σ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)A human author, patient, practitioner, or related person, as opposed to an organization or device
... asserter Σ0..1Reference(US Core Patient Profile | US Core Practitioner Profile | RelatedPerson)The person who provided the information, not necessarily the patient
... performer ΣI0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example)
.... actor Σ1..1Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | RelatedPerson | US Core Device Profile)Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3
.... onBehalfOf 0..1Reference(US Core Organization Profile)Organization the device or practitioner was acting for
... location Σ0..1Reference(US Core Location Profile)Where the procedure happened
... reasonCode Σ0..1CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example)
... reasonReference Σ0..1Reference(obf-Condition | obf-Observation | obf-Procedure | obf-DiagnosticReport | US Core DocumentReference Profile)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: BodyLocationVS (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... laterality 0..*Laterality
.... anatomicalorientation 0..*AnatomicalOrientation
.... relationtolandmark 0..*RelationToLandmark
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example)
... report 0..*Reference(obf-DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example)
... complicationDetail 0..*Reference(obf-Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example)
... note 0..*AnnotationAdditional information about the procedure
... focalDevice I0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (required)
.... manipulated 1..1Reference(US Core Device Profile)Device that was changed
... usedReference 0..*Reference(US Core Device Profile | US Core Medication Profile | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example)

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Max Binding: AllLanguages
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codeextensibleUSCoreProcedureCodes
Max Binding: US Core Procedure Codes
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySitepreferredBodyLocationVS
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionrequiredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

 

Constraints

IdPathDetailsRequirements
dom-2ProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-4ProcedureIf 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-3ProcedureIf 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-6ProcedureA resource should have narrative for robust management
: text.div.exists()
dom-5ProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
ele-1Procedure.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDeviceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())