This page is part of the Quality Improvement Core Framework (v2.0.0: STU 2) based on FHIR R3. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions 
| Appendectomy Example |
The official URL for this profile is:
http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
This profile builds on US Core Procedure Profile.
This profile was published on Fri Feb 27 18:00:00 AEDT 2015 as a draft by Health Level Seven International (Clinical Quality Information - QICore).
Description of Profiles, Differentials, and Snapshots.
Summary
Mandatory: 0 element (2 nested mandatory elements)
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | I | 0..* | An action that is being or was performed on a patient | |
  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: Common Languages (extensible) | |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
 contained | 0..* | Resource | Contained, inline Resources | |
 qicore-procedurerequest-approachBodySite | 0..* | Reference(QICore-BodySite) | Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite | |
| procedure-incisionDateTime | I | 0..1 | dateTime | Extension URL: http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
 definition | Σ | 0..* | Reference(PlanDefinition), Reference(ActivityDefinition), Reference(HealthcareService) | Instantiates protocol or definition |
| basedOn | Σ | 0..* | Reference(CarePlan), Reference(ProcedureRequest), Reference(ReferralRequest) | A request for this procedure |
| partOf | Σ | 0..* | Reference(Procedure), Reference(Observation), Reference(MedicationAdministration) | Part of referenced event |
| status | ?!SΣ | 1..1 | code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
| notDone | ?!Σ | 0..1 | boolean | True if procedure was not performed as scheduled |
| notDoneReason | ΣI | 0..1 | CodeableConcept | Reason procedure was not performed Binding: Procedure Not Performed Reason (SNOMED-CT) (example) |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: Procedure Category Codes (SNOMED CT) (example) |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code (preferred) |
| subject | SΣ | 1..1 | Reference(QICore-Patient), Reference(Group) | Who the procedure was performed on |
| context | SΣ | 0..1 | Reference(QICore-Encounter), Reference(Group) | Encounter or episode associated with the procedure |
 performed[x] | SΣ | 1..1 | dateTime, Period | Date/Period the procedure was performed |
| performer | SΣI | 0..* | BackboneElement | The people who performed the procedure |
 id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| role | Σ | 0..1 | CodeableConcept | The role the actor was in Binding: Procedure Performer Role Codes (example) |
| actor | Σ | 1..1 | Reference(QICore-Practitioner), Reference(QICore-Organization), Reference(QICore-Patient), Reference(QICore-RelatedPerson) | The reference to the practitioner |
 onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(QICore-Location) | Where the procedure happened |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Procedure Reason Codes (example) |
| reasonReference | Σ | 0..* | Reference(Condition), Reference(Observation) | Condition that is the reason the procedure performed |
| bodySite | SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMED CT Body Structures (example) |
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: Procedure Outcome Codes (SNOMED CT) (example) |
| report | S | 0..* | Reference(QICore-DiagnosticReport) | Any report resulting from the procedure |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/Diagnosis Codes (example) | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: Procedure Follow up Codes (SNOMED CT) (example) | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | I | 0..* | BackboneElement | Device changed in procedure |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| action | 0..1 | CodeableConcept | Kind of change to device Binding: Procedure Device Action Codes (preferred) | |
| manipulated | 1..1 | Reference(QICore-Device) | Device that was changed | |
| usedReference | 0..* | Reference(Device), Reference(Medication), Reference(Substance) | Items used during procedure | |
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIR Device Types (example) | |
| Documentation for this format | ||||
Summary
Mandatory: 0 element (2 nested mandatory elements)
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | I | 0..* | An action that is being or was performed on a patient | |
| 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: Common Languages (extensible) | |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| qicore-procedurerequest-approachBodySite | 0..* | Reference(QICore-BodySite) | Extension URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite | |
| procedure-incisionDateTime | I | 0..1 | dateTime | Extension URL: http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
| definition | Σ | 0..* | Reference(PlanDefinition), Reference(ActivityDefinition), Reference(HealthcareService) | Instantiates protocol or definition |
| basedOn | Σ | 0..* | Reference(CarePlan), Reference(ProcedureRequest), Reference(ReferralRequest) | A request for this procedure |
| partOf | Σ | 0..* | Reference(Procedure), Reference(Observation), Reference(MedicationAdministration) | Part of referenced event |
| status | ?!SΣ | 1..1 | code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
| notDone | ?!Σ | 0..1 | boolean | True if procedure was not performed as scheduled |
| notDoneReason | ΣI | 0..1 | CodeableConcept | Reason procedure was not performed Binding: Procedure Not Performed Reason (SNOMED-CT) (example) |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: Procedure Category Codes (SNOMED CT) (example) |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code (preferred) |
| subject | SΣ | 1..1 | Reference(QICore-Patient), Reference(Group) | Who the procedure was performed on |
| context | SΣ | 0..1 | Reference(QICore-Encounter), Reference(Group) | Encounter or episode associated with the procedure |
| performed[x] | SΣ | 1..1 | dateTime, Period | Date/Period the procedure was performed |
| performer | SΣI | 0..* | BackboneElement | The people who performed the procedure |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| role | Σ | 0..1 | CodeableConcept | The role the actor was in Binding: Procedure Performer Role Codes (example) |
| actor | Σ | 1..1 | Reference(QICore-Practitioner), Reference(QICore-Organization), Reference(QICore-Patient), Reference(QICore-RelatedPerson) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(QICore-Location) | Where the procedure happened |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Procedure Reason Codes (example) |
| reasonReference | Σ | 0..* | Reference(Condition), Reference(Observation) | Condition that is the reason the procedure performed |
| bodySite | SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMED CT Body Structures (example) |
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: Procedure Outcome Codes (SNOMED CT) (example) |
| report | S | 0..* | Reference(QICore-DiagnosticReport) | Any report resulting from the procedure |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/Diagnosis Codes (example) | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: Procedure Follow up Codes (SNOMED CT) (example) | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | I | 0..* | BackboneElement | Device changed in procedure |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| action | 0..1 | CodeableConcept | Kind of change to device Binding: Procedure Device Action Codes (preferred) | |
| manipulated | 1..1 | Reference(QICore-Device) | Device that was changed | |
| usedReference | 0..* | Reference(Device), Reference(Medication), Reference(Substance) | Items used during procedure | |
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIR Device Types (example) | |
| Documentation for this format | ||||
| Path | Name | Conformance | ValueSet |
| Procedure.language | Common Languages | extensible | Common Languages |
| Procedure.status | EventStatus | required | EventStatus |
| Procedure.notDoneReason | Procedure Not Performed Reason (SNOMED-CT) | example | Procedure Not Performed Reason (SNOMED-CT) |
| Procedure.category | Procedure Category Codes (SNOMED CT) | example | Procedure Category Codes (SNOMED CT) |
| Procedure.code | ?ext | preferred | http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code |
| Procedure.performer.role | Procedure Performer Role Codes | example | Procedure Performer Role Codes |
| Procedure.reasonCode | Procedure Reason Codes | example | Procedure Reason Codes |
| Procedure.bodySite | SNOMED CT Body Structures | example | SNOMED CT Body Structures |
| Procedure.outcome | Procedure Outcome Codes (SNOMED CT) | example | Procedure Outcome Codes (SNOMED CT) |
| Procedure.complication | Condition/Problem/Diagnosis Codes | example | Condition/Problem/Diagnosis Codes |
| Procedure.followUp | Procedure Follow up Codes (SNOMED CT) | example | Procedure Follow up Codes (SNOMED CT) |
| Procedure.focalDevice.action | Procedure Device Action Codes | preferred | Procedure Device Action Codes |
| Procedure.usedCode | FHIR Device Types | example | FHIR Device Types |
| 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-1 | Procedure | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.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 : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
| pro-1 | Procedure | Reason not done is only permitted if notDone indicator is true : notDoneReason.empty() or notDone = true | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.performer | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ele-1 | Procedure.focalDevice | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |
© HL7.org 2011+. QICore STU 2 (v2.0.0) (based on FHIR v3.0.1) generated on Tue, Nov 21, 2017 21:03+1100. QA Page
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