FHIR Clinical Guidelines (v1.0.0) (STU1)

This page is part of the Clinical Guidelines (v1.0.0: STU 1) based on FHIR R4. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition-cpg-procedure

Introduction:

Examples:

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-procedure

Documents a procedure as an activity within the context of a computable clinical practice guideline

This profile builds on Procedure.

This profile was published on Thu Jun 06 00:00:00 UTC 2019 as a draft by Health Level Seven, Inc. - CDS WG.

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred

... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature

... identifier S0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical S0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Source
... basedOn S0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... status S1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... statusReason S0..1CodeableConceptReason for current status
... category S0..1CodeableConceptClassification of the procedure
... code S0..1CodeableConceptIdentification of the procedure
... subject S1..1Reference(Patient | Group)Who the procedure was performed on
... encounter S0..1Reference(Encounter)Encounter created as part of
... reasonCode S0..*CodeableConceptCoded reason procedure performed
... reasonReference S0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)Pertinent information

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred


... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical SΣ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Source
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn SΣ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason SΣ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .

... subject SΣ1..1Reference(Patient | Group)Who the procedure was performed on
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode SΣ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference SΣ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)Pertinent information
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred

... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature

... identifier S0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical S0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Source
... basedOn S0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... status S1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... statusReason S0..1CodeableConceptReason for current status
... category S0..1CodeableConceptClassification of the procedure
... code S0..1CodeableConceptIdentification of the procedure
... subject S1..1Reference(Patient | Group)Who the procedure was performed on
... encounter S0..1Reference(Encounter)Encounter created as part of
... reasonCode S0..*CodeableConceptCoded reason procedure performed
... reasonReference S0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)Pertinent information

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... cpg-instantiatesCaseFeature S0..1canonical(StructureDefinition)Definition of this case feature
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-instantiatesCaseFeature
... cpg-caseFeatureType S0..1codeasserted | inferred
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeatureType
Binding: CPG Case Feature Type (required): Whether the case feature is asserted or inferred


... cpg-caseFeaturePertinence S0..1codeweakly-positive | weakly-negative | strongly-positive | strongly-negative | pathognomonic
URL: http://hl7.org/fhir/uv/cpg/StructureDefinition/cpg-caseFeaturePertinence
Binding: CPG Case Feature Pertinence (required): Describes the pertinence of a case feature


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical SΣ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Source
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn SΣ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason SΣ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .

... subject SΣ1..1Reference(Patient | Group)Who the procedure was performed on
... encounter SΣ0..1Reference(Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode SΣ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference SΣ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)Pertinent information
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Max Binding: AllLanguages
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codeexampleProcedureCodes(SNOMEDCT)
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2ProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ProcedureIf 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-4ProcedureIf 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-5ProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1Procedure.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.extension:instantiatesCaseFeatureAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.extension:instantiatesCaseFeatureMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.extension:caseFeatureTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.extension:caseFeatureTypeMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.extension:caseFeaturePertinenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.extension:caseFeaturePertinenceMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.instantiatesCanonicalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.instantiatesUriAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.partOfAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.statusReasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performed[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.recorderAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.asserterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performer.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.performer.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.performer.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.performer.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.performer.functionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performer.actorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.performer.onBehalfOfAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.locationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.reasonCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.reasonReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.outcomeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.reportAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.complicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.complicationDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.followUpAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.noteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDeviceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDevice.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.focalDevice.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.focalDevice.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1Procedure.focalDevice.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1Procedure.focalDevice.actionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.focalDevice.manipulatedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.usedReferenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1Procedure.usedCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())