QI-Core Implementation Guide
6.0.0-ballot - ballot
QI-Core Implementation Guide
6.0.0-ballot - ballot
This page is part of the Quality Improvement Core Framework (v6.0.0-ballot: STU6 (v6.0.0) Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurenotdone | Version: 6.0.0-ballot | |||
| Active as of 2018-08-22 | Computable Name: QICoreProcedureNotDone | |||
Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
The Procedure and ProcedureNotDone profiles represent the positive and negative statements for a procedure.
The following example illustrates the use of the ProcedureNotDone profile:
define "Intermittent Pneumatic Compression Devices Not Applied":
[ProcedureNotDone: "Application of Intermittent Pneumatic Compression Devices (IPC)"] DeviceNotApplied
where DeviceNotApplied.statusReason in "Medical Reason"
or DeviceNotApplied.statusReason in "Patient Refusal"
| Negation Example with valuset | Procedure not performed due to complications; indicates that none of the procedures in the given not done value set were performed. |
| Negation Example with code | Procedure not performed due to complications; indicates that a specific procedure, by code, was not performed. |
For a more complete discussion of representation of negation within QICore and quality improvement artifacts, see the Negation in QI Core topic.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided |
  recorded | S | 1..1 | dateTime | When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
 status | S | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Fixed Value: not-done |
 statusReason | S | 1..1 | CodeableConcept | Reason for current status Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done |
  code | SC | 1..1 | CodeableConcept | (USCDI) Identification of the procedure |
  notDoneValueSet | SC | 0..1 | canonical(ValueSet) | What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
 subject | S | 1..1 | Reference(QICore Patient) | (USCDI) Who the procedure was performed on |
| performed[x] | S | 0..1 | dateTime S, Period, string, Age, Range | (USCDI) When the procedure was performed |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.statusReason | extensible | NegationReasonCodes |
| Id | Grade | Path(s) | Details | Requirements |
| pnd-1 | error | Procedure | to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| recorded | S | 1..1 | dateTime | When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: not-done |
| statusReason | SΣ | 1..1 | CodeableConcept | Reason for current status Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done |
| code | SΣC | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure |
| notDoneValueSet | SC | 0..1 | canonical(ValueSet) | What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
| subject | SΣ | 1..1 | Reference(QICore Patient) | (USCDI) Who the procedure was performed on |
  performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |
 performedDateTime | dateTime | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.status | required | Fixed Value: not-done |
| Procedure.statusReason | extensible | NegationReasonCodes |
| Procedure.code | extensible | USCoreProcedureCodes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | 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-4 | error | 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-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| pnd-1 | error | Procedure | to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() | |
| 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..* | USCoreProcedureProfile | An action that is being or was performed on a patient pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided | ||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| recorded | S | 1..1 | dateTime | When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded | ||||
| 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) | (USCDI) A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: not-done | ||||
| statusReason | SΣ | 1..1 | CodeableConcept | Reason for current status Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done | ||||
| 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 | SΣC | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| notDoneValueSet | SC | 0..1 | canonical(ValueSet) | What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | ||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | (USCDI) Who the procedure was performed on | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣC | 0..1 | (USCDI) 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 | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | Fixed Value: not-done | ||||
| Procedure.statusReason | extensible | NegationReasonCodes | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | ||||
| Procedure.code | extensible | USCoreProcedureCodes | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | ||||
| Procedure.reasonCode | example | ProcedureReasonCodes | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreProcedureProfile
Differential View
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided |
| recorded | S | 1..1 | dateTime | When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
| status | S | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Fixed Value: not-done |
| statusReason | S | 1..1 | CodeableConcept | Reason for current status Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done |
| code | SC | 1..1 | CodeableConcept | (USCDI) Identification of the procedure |
| notDoneValueSet | SC | 0..1 | canonical(ValueSet) | What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
| subject | S | 1..1 | Reference(QICore Patient) | (USCDI) Who the procedure was performed on |
| performed[x] | S | 0..1 | dateTime S, Period, string, Age, Range | (USCDI) When the procedure was performed |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.statusReason | extensible | NegationReasonCodes |
| Id | Grade | Path(s) | Details | Requirements |
| pnd-1 | error | Procedure | to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| recorded | S | 1..1 | dateTime | When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: not-done |
| statusReason | SΣ | 1..1 | CodeableConcept | Reason for current status Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done |
| code | SΣC | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure |
| notDoneValueSet | SC | 0..1 | canonical(ValueSet) | What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
| subject | SΣ | 1..1 | Reference(QICore Patient) | (USCDI) Who the procedure was performed on |
| performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |
| performedDateTime | dateTime | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.status | required | Fixed Value: not-done |
| Procedure.statusReason | extensible | NegationReasonCodes |
| Procedure.code | extensible | USCoreProcedureCodes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | 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-4 | error | 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-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| pnd-1 | error | Procedure | to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided : code.extension('http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists() xor code.coding.exists() | |
| 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..* | USCoreProcedureProfile | An action that is being or was performed on a patient pnd-1: to indicate what procedure was not performed, either at least one coding in the code or a notDoneValueSet extension shall be provided | ||||
| 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.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| recorded | S | 1..1 | dateTime | When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded | ||||
| 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) | (USCDI) A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Fixed Value: not-done | ||||
| statusReason | SΣ | 1..1 | CodeableConcept | Reason for current status Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done | ||||
| 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 | SΣC | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| notDoneValueSet | SC | 0..1 | canonical(ValueSet) | What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet | ||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | (USCDI) Who the procedure was performed on | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣC | 0..1 | (USCDI) 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 | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | Fixed Value: not-done | ||||
| Procedure.statusReason | extensible | NegationReasonCodes | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | ||||
| Procedure.code | extensible | USCoreProcedureCodes | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | ||||
| Procedure.reasonCode | example | ProcedureReasonCodes | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreProcedureProfile
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ http://www.hl7.org/Special/committees/cqi/index.cfm. Package hl7.fhir.us.qicore#6.0.0-ballot based on FHIR 4.0.1. Generated 2023-08-03
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