Example Usage Scenarios:

The following are example usage scenarios for this profile:

• Query for procedures performed on a Patient
• Record or update a procedure performed on a Patient

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Procedure Must Have:

1. a status
2. a code that identifies the type of procedure performed on the patient*
3. a patient
4. when the procedure was performed*

Each Procedure Must Support:

1. the encounter associated with the procedure

Additional USCDI Requirements:

This Additional USCDI Requirements element is not Mandatory or Must Support but is required for ONC Health IT certification testing and is included in the formal definition of the profile and the Procedure examples.

1. a reason or indication for referral or consultation*

*see guidance below

Profile Specific Implementation Guidance:

• *The Procedure.code is mandatory if Procedure.status is ‘completed’ or ‘in-progress’.
• *The Procedure.code has an additional binding of “current” and a base “preferred” binding.
  • For the conformance rules on the current binding for coded data, review this section in the General Requirements page.
  • Procedure codes can be taken from SNOMED-CT, CPT, HCPCS II, ICD-10-PCS, CDT, or LOINC.
    • Only LOINC concepts that reflect actual procedures SHOULD be used
• A procedure including an implantable device SHOULD use Procedure.focalDevice referencing the US Core Implantable Device Profile.

• See the Screening and Assessments guidance page for more information when exchanging Social Determinants of Health (SDOH) Procedures

• *Servers and Clients SHALL support both US Core ServiceRequest and US Core Procedure Profiles for communicating the reason or justification for a referral as Additional USCDI Requirements. Typically, the reason or justification for a referral or consultation is communicated through Procedure.basedOn linking the Procedure to the US Core ServiceRequest Profile that includes either ServiceRequest.reasonCode or ServiceRequest.reasonReference. When the Procedure does not have an associated ServiceRequest, it is communicated through the US Core Procedure Profile’s Procedure.reasonCode or Procedure.reasonReference. Depending on the procedure being documented, a server will select the appropriate Profile to use.
  • Although both Procedure.reasonCode and Procedure.reasonReference are marked as Additional USCDI Requirements, the certifying server system is not required to support both, but SHALL support at least one of these elements. The certifying client application SHALL support both elements.
    • when using Procedure.reasonReference:
      • Servers SHALL support at least one target resource in Procedure.reasonReference. Clients SHALL support all target resources in Procedure.reasonReference.
      • The referenced resources SHOULD be a US Core Profile as documented in Referencing US Core Profiles.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	Procedure	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
basedOn		0..*	Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
status	SC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
code	S	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure Additional Bindings Purpose US Core Procedure Codes Current
subject	S	1..1	Reference(US Core Patient Profile S | Group)	Who the procedure was performed on
encounter	S	0..1	Reference(US Core Encounter Profile)	Encounter associated with the procedure
performed[x]	SC	0..1		When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
reasonCode		0..*	CodeableConcept	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed Binding: US Core Condition Codes (extensible)
reasonReference		0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.code	preferred	USCoreProcedureCodes Additional Bindings Purpose Documentation US Core Procedure Codes Current US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data. http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code from this IG
Procedure.reasonCode	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	Procedure	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
basedOn	Σ	0..*	Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure Additional Bindings Purpose US Core Procedure Codes Current
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who the procedure was performed on
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter associated with the procedure
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime
reasonCode	Σ	0..*	CodeableConcept	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed Binding: US Core Condition Codes (extensible)
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.code	preferred	USCoreProcedureCodes Additional Bindings Purpose Documentation US Core Procedure Codes Current US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data. http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code from this IG
Procedure.reasonCode	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	Procedure	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
id	Σ	0..1	id	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): A human language. Additional Bindings Purpose AllLanguages Max Binding
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(US Core CarePlan Profile | US Core ServiceRequest Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	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	Identification of the procedure Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure Additional Bindings Purpose US Core Procedure Codes Current
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group)	Who the procedure was performed on
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter associated with the procedure
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
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	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed Binding: US Core Condition Codes (extensible)
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	preferred	USCoreProcedureCodes Additional Bindings Purpose Documentation US Core Procedure Codes Current US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data. http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code from this IG
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	Procedure	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
basedOn		0..*	Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
status	SC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
code	S	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure Additional Bindings Purpose US Core Procedure Codes Current
subject	S	1..1	Reference(US Core Patient Profile S | Group)	Who the procedure was performed on
encounter	S	0..1	Reference(US Core Encounter Profile)	Encounter associated with the procedure
performed[x]	SC	0..1		When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
reasonCode		0..*	CodeableConcept	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed Binding: US Core Condition Codes (extensible)
reasonReference		0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.code	preferred	USCoreProcedureCodes Additional Bindings Purpose Documentation US Core Procedure Codes Current US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data. http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code from this IG
Procedure.reasonCode	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	Procedure	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
basedOn	Σ	0..*	Reference(US Core CarePlan Profile | US Core ServiceRequest Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure Additional Bindings Purpose US Core Procedure Codes Current
subject	SΣ	1..1	Reference(US Core Patient Profile)	Who the procedure was performed on
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter associated with the procedure
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime
reasonCode	Σ	0..*	CodeableConcept	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed Binding: US Core Condition Codes (extensible)
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.code	preferred	USCoreProcedureCodes Additional Bindings Purpose Documentation US Core Procedure Codes Current US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data. http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code from this IG
Procedure.reasonCode	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	Procedure	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
id	Σ	0..1	id	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): A human language. Additional Bindings Purpose AllLanguages Max Binding
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(US Core CarePlan Profile | US Core ServiceRequest Profile)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	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	Identification of the procedure Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure Additional Bindings Purpose US Core Procedure Codes Current
subject	SΣ	1..1	Reference(US Core Patient Profile S | Group)	Who the procedure was performed on
encounter	SΣ	0..1	Reference(US Core Encounter Profile)	Encounter associated with the procedure
performed[x]	SΣC	0..1		When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
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	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Coded reason procedure performed Binding: US Core Condition Codes (extensible)
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: US Core Profile justifying the reason procedure performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
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

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	preferred	USCoreProcedureCodes Additional Bindings Purpose Documentation US Core Procedure Codes Current US Core uses the current additional binding from FHIR R5 for this coded element for more flexibility when exchanging legacy and text-only data. http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	extensible	USCoreConditionCodes http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code from this IG
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from Procedure

Summary

Mandatory: 1 element
Must-Support: 5 elements

Structures

This structure refers to these other structures:

• US Core CarePlan Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-careplan)
• US Core ServiceRequest Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-servicerequest)
• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Maturity: 3

Quick Start

Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

• See the Scopes Format section for a description of the SMART scopes syntax.
• See the Search Syntax section for a description of the US Core search syntax.
• See the General Requirements section for additional rules and expectations when a server requires status parameters.
• See the General Guidance section for additional guidance on searching for multiple patients.

US Core Scopes

Servers providing access to procedure data SHALL support these US Core SMART Scopes:

• resource level scopes: <patient|user|system>/Procedure.rs

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

1. SHALL support searching for all procedures for a patient using the patient search parameter:

   GET [base]/Procedure?patient={Type/}[id]

   Example:

   1. GET [base]/Procedure?patient=1291938

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient (how to search by reference)

2. SHALL support searching using the combination of the patient and date search parameters:

   • including support for these date comparators: gt,lt,ge,le
   • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

   GET [base]/Procedure?patient={Type/}[id]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

   Example:

   1. GET [base]/Procedure?patient=1137192&date=ge2019-01-14

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date (how to search by reference and how to search by token)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

1. SHOULD support searching using the combination of the patient and status search parameters:
   • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

   GET [base]/Procedure?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

   Example:

   1. GET [base]/Procedure?patient=1137192&status=completed

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and status (how to search by reference and how to search by token)

2. SHOULD support searching using the combination of the patient and code and date search parameters:
   • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
   • including support for these date comparators: gt,lt,ge,le
   • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

   GET [base]/Procedure?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

   Example:

   1. GET [base]/Procedure?patient=1137192&date=ge2019-01-14T00:00:00Z&code=http://snomed.info/sct|35637008

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date and procedure code(s). SHOULD support search by multiple codes. (how to search by reference and how to search by token and how to search by date)