QICoreProcedure

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

Field	Card.	Type	Description
approachBodyStructure	0..*	List<Extension>	The approach body site used for this procedure. Multiple locations are allowed.
incisionDateTime	0..1	Extension	The time of the first incision.
identifier	0..*	List<Identifier>	Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.
instantiatesCanonical	0..*	List<canonical>	The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
instantiatesUri	0..*	List<String>	The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
basedOn	0..*	List<QICoreCarePlan | QICoreServiceNotRequested>	A reference to a resource that contains details of the request for this procedure.
partOf	0..*	List<QICoreProcedure | QICoreObservation | QICoreMedicationAdministration>	A larger event of which this particular procedure is a component or step.
status	1..1	String	A 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)
statusReason	0..1	Concept	Captures the reason for the current state of the procedure. Binding: A code that identifies the reason a procedure was not performed. (example)
category	0..1	Concept	A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Binding: A code that classifies a procedure for searching, sorting and display purposes. (example)
code	1..1	Concept	The 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)
subject	1..1	QICorePatient	The person, animal or group on which the procedure was performed.
encounter	0..1	QICoreEncounter	The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
performed[x]	1..1	DateTime | 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.
recorder	0..1	QICorePatient | QICoreRelatedPerson | QICorePractitioner | QICorePractitionerRole	Individual who recorded the record and takes responsibility for its content.
asserter	0..1	QICorePatient | QICoreRelatedPerson | QICorePractitioner | QICorePractitionerRole	Individual who is making the procedure statement.
performer	0..*	List<performer>	Limited to "real" people rather than equipment.
location	0..1	QICoreLocation	The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
reasonCode	0..*	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)
reasonReference	0..*	List<QICoreCondition | QICoreObservation | QICoreProcedure | QICoreDiagnosticReportLab | DocumentReference>	The justification of why the procedure was performed.
bodySite	0..*	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)
outcome	0..1	Concept	The 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)
report	0..*	List<QICoreDiagnosticReportNote>	This could be a histology result, pathology report, surgical report, etc.
complication	0..*	List<Concept>	Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. Binding: Codes describing complications that resulted from a procedure. (example)
complicationDetail	0..*	List<QICoreCondition>	Any complications that occurred during the procedure, or in the immediate post-performance period.
followUp	0..*	List<Concept>	If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. Binding: Specific follow up required for a procedure e.g. removal of sutures. (example)
note	0..*	List<Annotation>	Any other notes and comments about the procedure.
focalDevice	0..*	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.
usedReference	0..*	List<QICoreDevice | QICoreMedication | QICoreSubstance>	Identifies medications, devices and any other substance used as part of the procedure.
usedCode	0..*	List<Concept>	Identifies coded items that were used as part of the procedure. Binding: Codes describing items used during a procedure. (example)