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
| Field | Card. | Type | Description |
|---|---|---|---|
| recorded | 1..1 | Extension | An Extension |
| 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: A code specifying the state of the procedure. (required) |
| statusReason | 1..1 | Concept | Captures the reason for the current state of the procedure. Binding: The reason the procedure was not done (extensible) |
| 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 | 0..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: A code to identify a specific procedure . (example) |
| notDoneValueSet | 1..1 | Extension | Specifies the value set that characterizes the events or activities that did not occur or were not performed. |
| 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] | 0..1 | DateTime | 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. |
| 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<QICoreDiagnosticReportLab | DocumentReference | Composition> | 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) |