QI-Core Implementation Guide
7.0.0 - STU 7 United States of America flag

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

Example Procedure: Procedure positive example

Page standards status: Informative

Extension Definition for Procedure.recorded for Version 5.0: 2013-04-05 09:35:00-0400

status: Completed

code: Excision of appendix (procedure)

subject: Jim Chalmers Male, DoB: 1974-12-25 ( Medical record number (use: usual, period: 2001-05-06 --> (ongoing)))

encounter: Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP); type = Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.

performed: 2013-04-05 09:20:00-0400 --> 2013-04-05 10:30:00-0400

Performers

-Actor
*Dr Cecil Surgeon

reasonCode: Abdominal pain (finding)

bodySite: Appendix structure

report: Diagnostic Report for 'CBC panel - Blood by Automated count' for '->Peter Chalmers'