This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v0.9.1: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions
The official URL for this profile is:
http://hl7.org/fhir/us/mcode/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 Thu Aug 01 00:00:00 EDT 2019 as a active by HL7 International 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
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | I | 0..* | obf-Procedure | |
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) Max Binding: AllLanguages | |
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 Slice: Unordered, Open by value:url | |
obf-StatementDateTime-extension | 0..1 | dateTime | StatementDateTime URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-StatementDateTime-extension | |
obf-TreatmentIntent-extension | 0..1 | CodeableConcept | TreatmentIntent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-TreatmentIntent-extension Binding: TreatmentIntentVS (required) | |
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..1 | Reference(ServiceRequest) | A request for this procedure |
partOf | Σ | 0..1 | Reference(obf-Procedure | MedicationAdministration | obf-Observation) | Part of referenced event |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) |
code | SΣ | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (extensible) Max Binding: US Core Procedure Codes |
subject | SΣ | 1..1 | Reference(obf-Patient) | Who the procedure was performed on |
encounter | Σ | 0..1 | Reference(US Core Encounter Profile) | Encounter created as part of |
performed[x] | SΣ | 1..1 | dateTime, Period | When the procedure was performed |
recorder | Σ | 0..1 | Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson) | A human author, patient, practitioner, or related person, as opposed to an organization or device |
asserter | Σ | 0..1 | Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson) | The person who provided the information, not necessarily the patient |
performer | ΣI | 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) |
actor | Σ | 1..1 | Reference(US Core Practitioner Profile | US Core Organization Profile | obf-Patient | RelatedPerson | US Core Device Profile) | Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3 |
onBehalfOf | 0..1 | Reference(US Core Organization Profile) | Organization the device or practitioner was acting for | |
location | Σ | 0..1 | Reference(US Core Location Profile) | Where the procedure happened |
reasonCode | Σ | 0..1 | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example) |
reasonReference | Σ | 0..1 | Reference(obf-Condition | obf-Observation | obf-Procedure | obf-DiagnosticReport | US Core DocumentReference Profile) | The justification that the procedure was performed |
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: BodyLocationVS (preferred) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
obf-datatype-Laterality-extension | 0..* | CodeableConcept | Laterality URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-Laterality-extension Binding: Laterality (extensible) | |
obf-datatype-AnatomicalOrientation-extension | 0..* | CodeableConcept | AnatomicalOrientation URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-AnatomicalOrientation-extension Binding: AnatomicalOrientationVS (extensible) | |
obf-datatype-RelationToLandmark-extension | 0..* | (Complex) | RelationToLandmark URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-RelationToLandmark-extension | |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
text | Σ | 0..1 | string | Plain text representation of the concept |
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
report | 0..* | Reference(obf-DiagnosticReport) | Any report resulting from the procedure | |
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) | |
complicationDetail | 0..* | Reference(obf-Condition) | A condition that is a result of the procedure | |
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) | |
note | 0..* | Annotation | Additional information about the procedure | |
focalDevice | I | 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 (required) | |
manipulated | 1..1 | Reference(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..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example) | |
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
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | I | 0..* | obf-Procedure | |
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) Max Binding: AllLanguages | |
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 Slice: Unordered, Open by value:url | |
obf-StatementDateTime-extension | 0..1 | dateTime | StatementDateTime URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-StatementDateTime-extension | |
obf-TreatmentIntent-extension | 0..1 | CodeableConcept | TreatmentIntent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-TreatmentIntent-extension Binding: TreatmentIntentVS (required) | |
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..1 | Reference(ServiceRequest) | A request for this procedure |
partOf | Σ | 0..1 | Reference(obf-Procedure | MedicationAdministration | obf-Observation) | Part of referenced event |
status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) |
code | SΣ | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (extensible) Max Binding: US Core Procedure Codes |
subject | SΣ | 1..1 | Reference(obf-Patient) | Who the procedure was performed on |
encounter | Σ | 0..1 | Reference(US Core Encounter Profile) | Encounter created as part of |
performed[x] | SΣ | 1..1 | dateTime, Period | When the procedure was performed |
recorder | Σ | 0..1 | Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson) | A human author, patient, practitioner, or related person, as opposed to an organization or device |
asserter | Σ | 0..1 | Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson) | The person who provided the information, not necessarily the patient |
performer | ΣI | 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) |
actor | Σ | 1..1 | Reference(US Core Practitioner Profile | US Core Organization Profile | obf-Patient | RelatedPerson | US Core Device Profile) | Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3 |
onBehalfOf | 0..1 | Reference(US Core Organization Profile) | Organization the device or practitioner was acting for | |
location | Σ | 0..1 | Reference(US Core Location Profile) | Where the procedure happened |
reasonCode | Σ | 0..1 | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example) |
reasonReference | Σ | 0..1 | Reference(obf-Condition | obf-Observation | obf-Procedure | obf-DiagnosticReport | US Core DocumentReference Profile) | The justification that the procedure was performed |
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: BodyLocationVS (preferred) |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |
obf-datatype-Laterality-extension | 0..* | CodeableConcept | Laterality URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-Laterality-extension Binding: Laterality (extensible) | |
obf-datatype-AnatomicalOrientation-extension | 0..* | CodeableConcept | AnatomicalOrientation URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-AnatomicalOrientation-extension Binding: AnatomicalOrientationVS (extensible) | |
obf-datatype-RelationToLandmark-extension | 0..* | (Complex) | RelationToLandmark URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-RelationToLandmark-extension | |
coding | Σ | 0..* | Coding | Code defined by a terminology system |
text | Σ | 0..1 | string | Plain text representation of the concept |
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
report | 0..* | Reference(obf-DiagnosticReport) | Any report resulting from the procedure | |
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) | |
complicationDetail | 0..* | Reference(obf-Condition) | A condition that is a result of the procedure | |
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) | |
note | 0..* | Annotation | Additional information about the procedure | |
focalDevice | I | 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 (required) | |
manipulated | 1..1 | Reference(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..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example) | |
Documentation for this format |
Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML 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 | extensible | USCoreProcedureCodes Max Binding: US Core Procedure Codes |
Procedure.performer.function | example | ProcedurePerformerRoleCodes |
Procedure.reasonCode | example | ProcedureReasonCodes |
Procedure.bodySite | preferred | BodyLocationVS |
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) |
Procedure.complication | example | Condition/Problem/DiagnosisCodes |
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) |
Procedure.focalDevice.action | required | 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-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-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-6 | Procedure | A resource should have narrative for robust management : text.div.exists() | |
dom-5 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
ele-1 | Procedure.performer | 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()) |