This page is part of the Data Access Framework (v1.6.0: STU 2 Ballot 1) based on FHIR v1.6.0. . For a full list of available versions, see the Directory of published versions
Definitions for the daf-procedure Profile.
Procedure(DAFProcedure) | |
Definition | An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy. |
Control | 0..* |
Invariants | Defined on this element dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative (xpath: not(parent::f:contained and f:text)) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (xpath: not(parent::f:contained and f:contained)) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource (xpath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (xpath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))) pro-1: Reason not performed is only permitted if notPerformed indicator is true (xpath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true()) |
Procedure.id | |
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. |
Control | 0..1 |
Type | id |
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
Procedure.meta | |
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. |
Control | 0..1 |
Type | Meta |
Procedure.implicitRules | |
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. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | 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 as much as possible. |
Procedure.language | |
Definition | The base language in which the resource is written. |
Control | 0..1 |
Binding | A human language. The codes SHALL be taken from Common Languages; other codes may be used where these codes are not suitable |
Type | code |
Comments | 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). |
Procedure.text | |
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. |
Control | 0..1 This element is affected by the following invariants: dom-1 |
Type | Narrative |
Alternate Names | narrative, html, xhtml, display |
Comments | 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. |
Procedure.contained | |
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. |
Control | 0..* |
Type | Resource |
Alternate Names | inline resources, anonymous resources, contained resources |
Comments | 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. |
Procedure.extension | |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | 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. |
Procedure.modifierExtension | |
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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content |
Comments | 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. |
Procedure.identifier | |
Definition | This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). |
Note | This is a business identifer, not a resource identifier (see discussion) |
Control | 1..* |
Type | Identifier |
Must Support | true |
Requirements | Need to allow connection to a wider workflow. |
Procedure.subject | |
Definition | Demographics and other administrative information about an individual or animal receiving care or other health-related services. |
Control | 1..1 |
Type | Reference(Profile daf-patient) |
Must Support | true |
Alternate Names | SubjectOfCare Client Resident |
Procedure.status | |
Definition | A code specifying the state of the procedure. Generally this will be in-progress or completed state. |
Control | 1..1 |
Binding | null The codes SHALL be taken from ProcedureStatus |
Type | code |
Is Modifier | true |
Must Support | true |
Procedure.category | |
Definition | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). |
Control | 0..1 |
Binding | A code that classifies a procedure for searching, sorting and display purposes. For example codes, see Procedure Category Codes (SNOMED CT) |
Type | CodeableConcept |
Procedure.code | |
Definition | The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). |
Control | 1..1 |
Binding | A code to identify a specific procedure . For example codes, see Procedure Codes (SNOMED CT) |
Type | CodeableConcept |
Must Support | true |
Procedure.code.id | |
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
Procedure.code.extension | |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | 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. |
Procedure.code.coding | |
Definition | A reference to a code defined by a terminology system. |
Control | 0..* |
Type | Coding |
Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. |
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true. |
Procedure.code.coding(DAFProcedureCode) | |
Definition | A reference to a code defined by a terminology system. |
Control | 0..* |
Type | Coding |
Must Support | true |
Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. |
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true. |
Procedure.code.coding | |
Definition | A reference to a code defined by a terminology system. |
Control | 1..1 |
Binding | Codes describing the Procedure Type The codes SHALL be taken from DAFProcedureType |
Type | Coding |
Must Support | true |
Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. |
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true. |
Procedure.code.coding | |
Definition | A reference to a code defined by a terminology system. |
Control | 0..1 |
Binding | Optional ICD-10PCS Code translations describing the Procedure Type The codes SHALL be taken from DAF Procedure Type ICD-10-PCS Codes |
Type | Coding |
Must Support | true |
Requirements | Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. |
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true. |
Procedure.code.text | |
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. |
Control | 0..1 |
Type | string |
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. |
Comments | Very often the text is the same as a displayName of one of the codings. |
Procedure.notPerformed | |
Definition | Set this to true if the record is saying that the procedure was NOT performed. |
Control | 0..1 |
Type | boolean |
Is Modifier | true |
Default Value | false |
Procedure.reasonNotPerformed | |
Definition | A code indicating why the procedure was not performed. |
Control | 0..* This element is affected by the following invariants: pro-1 |
Binding | A code that identifies the reason a procedure was not performed. For example codes, see Procedure Not Performed Reason (SNOMED-CT) |
Type | CodeableConcept |
Procedure.bodySite | |
Definition | Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. |
Control | 0..* |
Binding | Codes describing anatomical locations. May include laterality. For example codes, see SNOMED CT Body Structures |
Type | CodeableConcept |
Procedure.reasonReference | |
Definition | The condition that is the reason why the procedure was performed. |
Control | 0..* |
Type | Reference(Condition) |
Comments | e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. |
Procedure.reasonCode | |
Definition | The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text. |
Control | 0..* |
Binding | A code that identifies the reason a procedure is required. For example codes, see Procedure Reason Codes |
Type | CodeableConcept |
Procedure.performer | |
Definition | Limited to 'real' people rather than equipment. |
Control | 0..* |
Type | BackboneElement |
Must Support | true |
Procedure.performer.id | |
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
Procedure.performer.extension | |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | 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. |
Procedure.performer.modifierExtension | |
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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content, modifiers |
Comments | 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. |
Procedure.performer.actor | |
Definition | This is basic constraint on provider for use in DAF resources. |
Control | 0..1 |
Type | Reference(Profile daf-pract) |
Must Support | true |
Alternate Names | Provider |
Comments | Note that a cab driver no longer fits the bill. You probably would be interested in the organization rather than the individual? |
Procedure.performer.role | |
Definition | For example: surgeon, anaethetist, endoscopist. |
Control | 0..1 |
Binding | A code that identifies the role of a performer of the procedure. For example codes, see Procedure Performer Role Codes |
Type | CodeableConcept |
Procedure.performed[x] | |
Definition | The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. |
Control | 0..1 |
Type | Choice of: dateTime, Period |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Must Support | true |
Procedure.encounter | |
Definition | An interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient. |
Control | 0..1 |
Type | Reference(Profile daf-encounter) |
Must Support | true |
Alternate Names | Visit |
Procedure.location | |
Definition | The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. |
Control | 0..1 |
Type | Reference(Location) |
Requirements | Ties a procedure to where the records are likely kept. |
Procedure.outcome | |
Definition | The outcome of the procedure - did it resolve reasons for the procedure being performed? |
Control | 0..1 |
Binding | An outcome of a procedure - whether it was resolved or otherwise. For example codes, see Procedure Outcome Codes (SNOMED CT) |
Type | CodeableConcept |
Comments | If outcome contains narrative text only, it can be captured using the CodeableConcept.text. |
Procedure.report | |
Definition | This could be a histology result, pathology report, surgical report, etc.. |
Control | 0..* |
Type | Reference(DiagnosticReport) |
Comments | There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports. |
Procedure.complication | |
Definition | Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. |
Control | 0..* |
Binding | Codes describing complications that resulted from a procedure. For example codes, see Condition/Problem/Diagnosis Codes |
Type | CodeableConcept |
Comments | If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. |
Procedure.followUp | |
Definition | If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used. |
Control | 0..* |
Binding | Specific follow up required for a procedure e.g. removal of sutures. For example codes, see Procedure Follow up Codes (SNOMED CT) |
Type | CodeableConcept |
Procedure.request | |
Definition | A reference to a resource that contains details of the request for this procedure. |
Control | 0..1 |
Type | Choice of: Reference(CarePlan), Reference(DiagnosticRequest), Reference(ProcedureRequest), Reference(ReferralRequest) |
Procedure.notes | |
Definition | Any other notes about the procedure. E.g. the operative notes. |
Control | 0..* |
Type | Annotation |
Procedure.focalDevice | |
Definition | A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. |
Control | 0..* |
Type | BackboneElement |
Procedure.focalDevice.id | |
Definition | unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Control | 0..1 |
Type | string |
Procedure.focalDevice.extension | |
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. |
Control | 0..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | 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. |
Procedure.focalDevice.modifierExtension | |
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. |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Alternate Names | extensions, user content, modifiers |
Comments | 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. |
Procedure.focalDevice.action | |
Definition | The kind of change that happened to the device during the procedure. |
Control | 0..1 |
Binding | A kind of change that happened to the device during the procedure. The codes SHALL be taken from Procedure Device Action Codes |
Type | CodeableConcept |
Procedure.focalDevice.manipulated | |
Definition | The device that was manipulated (changed) during the procedure. |
Control | 1..1 |
Type | Reference(Device) |
Procedure.usedReference | |
Definition | Identifies medications, devices and any other substance used as part of the procedure. |
Control | 0..* |
Type | Choice of: Reference(Device), Reference(Medication), Reference(Substance) |
Requirements | Used for tracking contamination, etc. |
Comments | For devices actually implanted or removed, use Procedure.device. |
Procedure.usedCode | |
Definition | Identifies coded items that were used as part of the procedure. |
Control | 0..* |
Binding | Codes describing items used during a procedure |
Type | CodeableConcept |
Comments | For devices actually implanted or removed, use Procedure.device. |
Procedure.component | |
Definition | Identifies medication administrations, other procedures or observations that are related to this procedure. |
Control | 0..* |
Type | Choice of: Reference(MedicationAdministration), Reference(Procedure), Reference(Observation) |