Procedure

The US Core Condition Profile is based upon the core FHIR Procedure Resource and created to meet the 2015 Edition Common Clinical Data Set 'Procedures' requirements.

= Must Support, = Is Modifier, = QiCore defined extension

FieldCard.TypeDescription
approachBodySite0..*List<Extension>The time of the first incision.
incisionDateTime0..1ExtensionThe time of the first incision.
status1..1StringA code specifying the state of the procedure. Generally, this will be the in-progress or completed state.
Binding: http://hl7.org/fhir/ValueSet/event-status (required)
code1..1ConceptThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
Binding: Codes describing the Procedure Type (preferred)
subject1..1PatientThe person, animal or group on which the procedure was performed.
encounter0..1Encounter | GroupThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
performed[x]1..1DateTime | Interval<DateTime>Estimated or actual date, date-time, period, or age when 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.
performer0..*List<performer>Limited to "real" people rather than equipment.
location0..1LocationThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
reasonCode0..*List<Concept>The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.
Binding: A code that identifies the reason a procedure is required. (example)
reasonReference0..*List<Condition | Observation | Procedure | DiagnosticReport | DocumentReference>The justification of why the procedure was performed.
bodySite0..*List<Concept>Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
Binding: Codes describing anatomical locations. May include laterality. (example)
outcome0..1ConceptThe outcome of the procedure - did it resolve the reasons for the procedure being performed?
Binding: An outcome of a procedure - whether it was resolved or otherwise. (example)
report0..*List<qicore-diagnosticreport>This could be a histology result, pathology report, surgical report, etc.
focalDevice0..*List<focalDevice>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.