QI-Core Implementation Guide
6.0.0 - STU6
QI-Core Implementation Guide
6.0.0 - STU6
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. For a full list of available versions, see the Directory of published versions
| 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.
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'
| Appendectomy Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
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 | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | NonNegativeEventStatushttp://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-statusfrom this IG | |
| Procedure.reasonCode | preferred | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom 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 | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | NonNegativeEventStatushttp://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-statusfrom this IG | |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.reasonCode | preferred | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard |
| 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() |
| 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' | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | (QI-Core) A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| 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 | ||||
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn | Σ | 0..* | Reference(QICore CarePlan | QICore ServiceRequest) | (QI-Core)(USCDI) A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| 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) | ||||
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| 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 | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |||||
| performedDateTime | dateTime S | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | Σ | 1..1 | Reference(QICore Practitioner | QICore Organization | QICore Patient | 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(Location) | Where the procedure happened | ||||
| 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 | ||||
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | 0..* | Annotation | Additional information about the procedure | |||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | NonNegativeEventStatushttp://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-statusfrom this IG | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | preferred | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| 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() |
This structure is derived from USCoreProcedureProfile
Summary
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
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 | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | NonNegativeEventStatushttp://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-statusfrom this IG | |
| Procedure.reasonCode | preferred | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard |
Key Elements View
| 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 | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | NonNegativeEventStatushttp://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-statusfrom this IG | |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.reasonCode | preferred | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard |
| 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() |
Snapshot View
| 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' | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | (QI-Core) A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| 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 | ||||
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn | Σ | 0..* | Reference(QICore CarePlan | QICore ServiceRequest) | (QI-Core)(USCDI) A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| 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) | ||||
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| 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 | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣC | 0..1 | (USCDI) When the procedure was performed | |||||
| performedDateTime | dateTime S | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | Σ | 1..1 | Reference(QICore Practitioner | QICore Organization | QICore Patient | 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(Location) | Where the procedure happened | ||||
| 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 | ||||
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | 0..* | Annotation | Additional information about the procedure | |||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | NonNegativeEventStatushttp://hl7.org/fhir/us/qicore/ValueSet/qicore-non-negative-event-statusfrom this IG | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | preferred | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| 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() |
This structure is derived from USCoreProcedureProfile
Summary
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#6.0.0 based on FHIR 4.0.1. Generated 2024-03-01
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