QICoreProcedureNotDone

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

= Must Support, = Is Modifier, = QiCore defined extension

FieldCard.TypeDescription
recorded1..1ExtensionAn Extension
identifier0..*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.
instantiatesCanonical0..*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.
instantiatesUri0..*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.
basedOn0..*List<QICoreCarePlan | QICoreServiceNotRequested>A reference to a resource that contains details of the request for this procedure.
partOf0..*List<QICoreProcedure | QICoreObservation | QICoreMedicationAdministration>A larger event of which this particular procedure is a component or step.
status1..1StringA code specifying the state of the procedure. Generally, this will be the in-progress or completed state.
Binding: A code specifying the state of the procedure. (required)
statusReason1..1ConceptCaptures the reason for the current state of the procedure.
Binding: The reason the procedure was not done (extensible)
category0..1ConceptA 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)
code0..1ConceptThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
Binding: A code to identify a specific procedure . (example)
notDoneValueSet1..1ExtensionSpecifies the value set that characterizes the events or activities that did not occur or were not performed.
subject1..1QICorePatientThe person, animal or group on which the procedure was performed.
encounter0..1QICoreEncounterThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
performed[x]0..1DateTime | Interval<DateTime> | String | Age | Interval<Quantity>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.
recorder0..1QICorePatient | QICoreRelatedPerson | QICorePractitioner | QICorePractitionerRoleIndividual who recorded the record and takes responsibility for its content.
asserter0..1QICorePatient | QICoreRelatedPerson | QICorePractitioner | QICorePractitionerRoleIndividual who is making the procedure statement.
performer0..*List<performer>Limited to "real" people rather than equipment.
location0..1QICoreLocationThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
reasonCode0..*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)
reasonReference0..*List<QICoreCondition | QICoreObservation | QICoreProcedure | QICoreDiagnosticReportLab | DocumentReference>The justification of why the procedure was performed.
bodySite0..*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)
outcome0..1ConceptThe 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)
report0..*List<QICoreDiagnosticReportLab | DocumentReference | Composition>This could be a histology result, pathology report, surgical report, etc.
complication0..*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)
complicationDetail0..*List<QICoreCondition>Any complications that occurred during the procedure, or in the immediate post-performance period.
followUp0..*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)
note0..*List<Annotation>Any other notes and comments about the procedure.
focalDevice0..*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.
usedReference0..*List<QICoreDevice | QICoreMedication | QICoreSubstance>Identifies medications, devices and any other substance used as part of the procedure.
usedCode0..*List<Concept>Identifies coded items that were used as part of the procedure.
Binding: Codes describing items used during a procedure. (example)