QI-Core Implementation Guide
7.0.0-ballot - STU7 Ballot United States of America flag

This page is part of the Quality Improvement Core Framework (v7.0.0-ballot: STU7 (v7.0.0) Ballot) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 7.0.1. For a full list of available versions, see the Directory of published versions

Resource Profile: QICore Procedure Not Done

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurenotdone Version: 7.0.0-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.

Must Have:
  • status: (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
  • code: (QI) Identification of the procedure
  • subject: (QI) Who the procedure was performed on
QI Elements:
  • recorded: (QI) When the procedure was first captured in the subject's record
  • basedOn: (QI) A request for this procedure
  • statusReason: (QI) Reason for the current status
  • notDoneValueSet: (QI) What was not performed
  • performed[x]: (QI) When the procedure was performed
Primary code path: code
(PCPath) This element is the primary code path for this resource CQL Retrieve


NOTE TO BALLOT REVIEWERS:
  • US Core 7.0, and thus QI-Core 7.0, has a new approach to USCDI requirements.
    • As noted in the US Core 7.0 Must Support section, US Core 7.0 no longer highlights mandatory (cardinality 1..* or 1..1) and Must Support elements with a (USCDI) indicator as such items must be supported for interoperability.
    • Those USCDI elements that are not mandatory or Must Support now include an indicator (ADDITIONAL USCDI) in US Core. QI-Core 7.0 does not reference USCDI elements; rather, users should access US Core 7.0 to understand its implementation of USCDI version 4.
  • We invite comments about the approach and suggestions for other options that would also avoid unnecessary noise or reading load to the QI-Core profile representation.
  • Further, QI-Core 7.0 does not discuss USCDI+Quality because at the time of ballot preparation, no published version of USCDI+Quality is available. We seek reviewer advice regarding how QI-Core might address future USCDI+Quality.

Usage

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"

See the patterns page for implementation and usage patterns.

Examples

Negation Example with valusetProcedure not performed due to complications; indicates that none of the procedures in the given not done value set were performed.
Negation Example with codeProcedure 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 QI-Core and quality improvement artifacts, see the Negation in QI-Core topic.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... Slices for extension Content/Rules for all slices
.... recorded 1..1 dateTime (QI) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
... basedOn Σ 0..* Reference(QICore CarePlan | QICore ServiceRequest) (QI) A request for this procedure
... status 1..1 code (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... code C 1..1 CodeableConcept (QI) Identification of the procedure
Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure

Additional BindingsPurpose
US Core Procedure Codes Required
.... Slices for extension Content/Rules for all slices
..... notDoneValueSet C 0..1 canonical(ValueSet) (QI) What was not performed
URL: http://hl7.org/fhir/StructureDefinition/cqf-notDoneValueSet
... subject 1..1 Reference(QICore Patient) (QI) Who the procedure was performed on
... performed[x] 0..1 dateTime, Period, string, Age, Range (QI) When the procedure was performed
... reasonCode 0..* CodeableConcept (QI) Coded reason procedure performed
Binding: US Core Condition Codes (extensible)
... reasonReference 0..* Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (QI) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.codepreferredUSCoreProcedureCodes
Additional Bindings Purpose Documentation
US Core Procedure Codes Required

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
Procedure.reasonCodeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code

Constraints

IdGradePath(s)DetailsRequirements
pnd-1errorProcedureto 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/StructureDefinition/cqf-notDoneValueSet').exists() xor code.coding.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile 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'
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 1..1 dateTime (QI) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ 1..1 CodeableConcept (QI) Reason for the current status
Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done

... code SΣC 1..1 CodeableConcept (QI) Identification of the procedure
Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure

Additional BindingsPurpose
US Core Procedure Codes Required
.... Slices for extension Content/Rules for all slices
..... notDoneValueSet C 0..1 canonical(ValueSet) (QI) What was not performed
URL: http://hl7.org/fhir/StructureDefinition/cqf-notDoneValueSet
... subject SΣ 1..1 Reference(QICore Patient) (QI) 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 (QI) When the procedure was performed
.... performedDateTime dateTime
... reasonCode Σ 0..* CodeableConcept (QI) Coded reason procedure performed
Binding: US Core Condition Codes (extensible)
... reasonReference Σ 0..* Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (QI) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.codepreferredUSCoreProcedureCodes
Additional Bindings Purpose Documentation
US Core Procedure Codes Required

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
Procedure.reasonCodeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto 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/StructureDefinition/cqf-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile 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'
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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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 1..1 dateTime (QI) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.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(QICore CarePlan | QICore ServiceRequest) (QI) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
... status ?!SΣC 1..1 code (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ 1..1 CodeableConcept (QI) Reason for the 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 (QI) Identification of the procedure
Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure

Additional BindingsPurpose
US Core Procedure Codes Required
.... 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 C 0..1 canonical(ValueSet) (QI) What was not performed
URL: http://hl7.org/fhir/StructureDefinition/cqf-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) (QI) 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 (QI) 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 (QI) Coded reason procedure performed
Binding: US Core Condition Codes (extensible)
... reasonReference Σ 0..* Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (QI) 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.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codepreferredUSCoreProcedureCodes
Additional Bindings Purpose Documentation
US Core Procedure Codes Required

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
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto 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/StructureDefinition/cqf-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed 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 USCoreProcedureProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... Slices for extension Content/Rules for all slices
.... recorded 1..1 dateTime (QI) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
... basedOn Σ 0..* Reference(QICore CarePlan | QICore ServiceRequest) (QI) A request for this procedure
... status 1..1 code (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... code C 1..1 CodeableConcept (QI) Identification of the procedure
Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure

Additional BindingsPurpose
US Core Procedure Codes Required
.... Slices for extension Content/Rules for all slices
..... notDoneValueSet C 0..1 canonical(ValueSet) (QI) What was not performed
URL: http://hl7.org/fhir/StructureDefinition/cqf-notDoneValueSet
... subject 1..1 Reference(QICore Patient) (QI) Who the procedure was performed on
... performed[x] 0..1 dateTime, Period, string, Age, Range (QI) When the procedure was performed
... reasonCode 0..* CodeableConcept (QI) Coded reason procedure performed
Binding: US Core Condition Codes (extensible)
... reasonReference 0..* Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (QI) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.codepreferredUSCoreProcedureCodes
Additional Bindings Purpose Documentation
US Core Procedure Codes Required

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
Procedure.reasonCodeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code

Constraints

IdGradePath(s)DetailsRequirements
pnd-1errorProcedureto 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/StructureDefinition/cqf-notDoneValueSet').exists() xor code.coding.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile 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'
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 1..1 dateTime (QI) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.recorded
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ 1..1 CodeableConcept (QI) Reason for the current status
Binding: QICore Negation Reason Codes (extensible): The reason the procedure was not done

... code SΣC 1..1 CodeableConcept (QI) Identification of the procedure
Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure

Additional BindingsPurpose
US Core Procedure Codes Required
.... Slices for extension Content/Rules for all slices
..... notDoneValueSet C 0..1 canonical(ValueSet) (QI) What was not performed
URL: http://hl7.org/fhir/StructureDefinition/cqf-notDoneValueSet
... subject SΣ 1..1 Reference(QICore Patient) (QI) 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 (QI) When the procedure was performed
.... performedDateTime dateTime
... reasonCode Σ 0..* CodeableConcept (QI) Coded reason procedure performed
Binding: US Core Condition Codes (extensible)
... reasonReference Σ 0..* Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (QI) The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.codepreferredUSCoreProcedureCodes
Additional Bindings Purpose Documentation
US Core Procedure Codes Required

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
Procedure.reasonCodeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto 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/StructureDefinition/cqf-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C 0..* USCoreProcedureProfile 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'
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.

Additional BindingsPurpose
AllLanguages Max Binding
... 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 1..1 dateTime (QI) When the procedure was first captured in the subject's record
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.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(QICore CarePlan | QICore ServiceRequest) (QI) A request for this procedure
... partOf Σ 0..* Reference(Procedure | Observation | MedicationAdministration) Part of referenced event
... status ?!SΣC 1..1 code (QI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required)
Fixed Value: not-done
... statusReason Σ 1..1 CodeableConcept (QI) Reason for the 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 (QI) Identification of the procedure
Binding: US Core Procedure Codes (preferred): Codes describing the type of Procedure

Additional BindingsPurpose
US Core Procedure Codes Required
.... 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 C 0..1 canonical(ValueSet) (QI) What was not performed
URL: http://hl7.org/fhir/StructureDefinition/cqf-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) (QI) 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 (QI) 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 (QI) Coded reason procedure performed
Binding: US Core Condition Codes (extensible)
... reasonReference Σ 0..* Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile) (QI) 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.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredFixed Value: not-done
http://hl7.org/fhir/ValueSet/event-status
from the FHIR Standard
Procedure.statusReasonextensibleNegationReasonCodes
http://hl7.org/fhir/us/qicore/ValueSet/qicore-negation-reason
from this IG
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codepreferredUSCoreProcedureCodes
Additional Bindings Purpose Documentation
US Core Procedure Codes Required

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
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeextensibleUSCoreConditionCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-condition-code
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
pnd-1errorProcedureto 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/StructureDefinition/cqf-notDoneValueSet').exists() xor code.coding.exists()
us-core-7errorProcedurePerformed SHALL be present if the status is 'completed' or 'in-progress'
: (status='completed' or status='in-progress') implies performed.exists()

 

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