QICore Procedure - QI-Core Implementation Guide v6.0.0

QI-Core Implementation Guide
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This page is part of the Quality Improvement Core Framework (v6.0.0: STU6 (v6.0.0)) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: QICore Procedure

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure				Version: 6.0.0
Active as of 2018-08-22				Computable Name: QICoreProcedure

Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Usage

To create an expression specifically requesting information that a procedure intentionally did not occur for a medical, patient or system reason, use the profile QICore-Procedurenotdone.

The following example illustrates the use of the Procedure profile:

define "Application of Intermittent Pneumatic Compression Devices":
  ["Procedure": "Application of Intermittent Pneumatic Compression Devices (IPC)"] DeviceApplied
    where DeviceApplied.status = 'completed'

See the patterns page for implementation and usage patterns.

Examples

Appendectomy Example

Usage:

Refer to this Resource Profile: QICore AdverseEvent, QICore Claim, QICore Encounter and QICore ImagingStudy
Examples for this Resource Profile: Procedure/example

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

Differential Table
Key Elements Table
Snapshot Table
Statistics/References
All

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure			USCoreProcedureProfile
implicitRules		0..1	uri	(QI-Core) A set of rules under which this content was created
recorded		0..1	dateTime	(QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
basedOn	Σ	0..*	Reference(QICore CarePlan \| QICore ServiceRequest)	(QI-Core)(USCDI) A request for this procedure
status		1..1	code	(QI-Core)(USCDI) preparation \| in-progress \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: Non-Negative Event Status (required)
subject		1..1	Reference(QICore Patient)	(QI-Core)(USCDI) Who the procedure was performed on
performer
actor		1..1	Reference(QICore Practitioner \| QICore Organization \| QICore Patient \| QICore RelatedPerson)	The reference to the practitioner
reasonCode		0..*	CodeableConcept	(QI-Core) Coded reason procedure performed Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
reasonReference		0..*	Reference(QICore Condition Encounter Diagnosis \| QICore Condition Problems Health Concerns \| QICore DiagnosticReport Profile for Report and Note Exchange \| US Core DocumentReference Profile)	(QI-Core) The justification that the procedure was performed
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.status	required	NonNegativeEventStatus `http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-status` from this IG
Procedure.reasonCode	preferred	ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	(QI-Core) A set of rules under which this content was created
recorded		0..1	dateTime	(QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
basedOn	Σ	0..*	Reference(QICore CarePlan \| QICore ServiceRequest)	(QI-Core)(USCDI) A request for this procedure
status	?!SΣC	1..1	code	(QI-Core)(USCDI) preparation \| in-progress \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: Non-Negative Event Status (required)
code	SΣ	1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
subject	SΣ	1..1	Reference(QICore Patient)	(QI-Core)(USCDI) Who the procedure was performed on
performed[x]	SΣC	0..1		(USCDI) When the procedure was performed
performedDateTime			dateTime
reasonCode	Σ	0..*	CodeableConcept	(QI-Core) Coded reason procedure performed Binding: ProcedureReasonCodes (preferred): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(QICore Condition Encounter Diagnosis \| QICore Condition Problems Health Concerns \| QICore DiagnosticReport Profile for Report and Note Exchange \| US Core DocumentReference Profile)	(QI-Core) The justification that the procedure was performed
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	NonNegativeEventStatus `http://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-status` from this IG
Procedure.code	extensible	USCoreProcedureCodes `http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code`
Procedure.reasonCode	preferred	ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	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-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	ALL elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	ALL extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()