International Patient Summary Implementation Guide
1.1.0 - STU 1 Update 1
International Patient Summary Implementation Guide
1.1.0 - STU 1 Update 1
This page is part of the International Patient Summary Implementation Guide (v1.1.0: STU 1) based on FHIR 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 
| Official URL: http://hl7.org/fhir/uv/ips/StructureDefinition/Procedure-uv-ips | Version: 1.1.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: ProcedureUvIps | ||
This profile represents the constraints applied to the Procedure resource by the IPS project, which specifies an entry of the History of Procedure for the international patient summary based on the FHIR standard R4.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||||
  status | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | |||||||
 code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Procedures - SNOMED CT + Absent/Unknown - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||
  subject | S | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on | ||||||
  reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| performed[x] | S | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed | ||||||
 data-absent-reason | S | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing. | ||||||
| asserter | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |||||||
| performer | 0..* | BackboneElement | The people who performed the procedure | |||||||
| actor | 1..1 | Reference(Patient (IPS) | RelatedPerson | Device - performer, observer | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS)) | The reference to the practitioner | |||||||
| onBehalfOf | 0..1 | Reference(Organization (IPS)) | Organization the device or practitioner was acting for | |||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | |||||||||
| Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||||
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Procedures - SNOMED CT + Absent/Unknown - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on | ||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
 performed[x] | SΣ | 1..1 | When the procedure was performed | |||||||
| performed[x]:All Types | Content/Rules for all Types | |||||||||
 data-absent-reason | S | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing. | ||||||
| performedDateTime | dateTime | |||||||||
| performedPeriod | Period | |||||||||
| performedString | string | |||||||||
| performedAge | Age | |||||||||
| performedRange | Range | |||||||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| actor | Σ | 1..1 | Reference(Patient (IPS) | RelatedPerson | Device - performer, observer | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS)) | The reference to the practitioner | ||||||
| onBehalfOf | 0..1 | Reference(Organization (IPS)) | Organization the device or practitioner was acting for | |||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | |||||||||
| Procedure.status | required | EventStatus | |||||||||
| Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| 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() |
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||||
| implicitRules | ?!Σ | 0..1 | uri | 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 | |||||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||||
| 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(CarePlan | ServiceRequest) | A request for this procedure | ||||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||||
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||||
| 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 | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Procedures - SNOMED CT + Absent/Unknown - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on | ||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
| performed[x] | SΣ | 1..1 | When the procedure was performed | |||||||
| performed[x]:All Types | Content/Rules for all Types | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| data-absent-reason | S | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing. | ||||||
| performedDateTime | dateTime | |||||||||
| 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(Patient (IPS) | RelatedPerson | Device - performer, observer | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS)) | The reference to the practitioner | ||||||
| onBehalfOf | 0..1 | Reference(Organization (IPS)) | Organization the device or practitioner was acting for | |||||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||||
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| 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 | ||||||||||
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
This structure is derived from Procedure
Summary
Mandatory: 3 elements
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||||
| status | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | |||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Procedures - SNOMED CT + Absent/Unknown - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||
| subject | S | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on | ||||||
| reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| performed[x] | S | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed | ||||||
| data-absent-reason | S | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing. | ||||||
| asserter | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |||||||
| performer | 0..* | BackboneElement | The people who performed the procedure | |||||||
| actor | 1..1 | Reference(Patient (IPS) | RelatedPerson | Device - performer, observer | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS)) | The reference to the practitioner | |||||||
| onBehalfOf | 0..1 | Reference(Organization (IPS)) | Organization the device or practitioner was acting for | |||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | |||||||||
| Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||||
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||||
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Procedures - SNOMED CT + Absent/Unknown - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on | ||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| performed[x] | SΣ | 1..1 | When the procedure was performed | |||||||
| performed[x]:All Types | Content/Rules for all Types | |||||||||
| data-absent-reason | S | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing. | ||||||
| performedDateTime | dateTime | |||||||||
| performedPeriod | Period | |||||||||
| performedString | string | |||||||||
| performedAge | Age | |||||||||
| performedRange | Range | |||||||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| actor | Σ | 1..1 | Reference(Patient (IPS) | RelatedPerson | Device - performer, observer | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS)) | The reference to the practitioner | ||||||
| onBehalfOf | 0..1 | Reference(Organization (IPS)) | Organization the device or practitioner was acting for | |||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| Documentation for this format | ||||||||||
| Path | Conformance | ValueSet | |||||||||
| Procedure.status | required | EventStatus | |||||||||
| Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| 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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||||
| implicitRules | ?!Σ | 0..1 | uri | 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 | |||||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||||
| 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(CarePlan | ServiceRequest) | A request for this procedure | ||||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||||
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||||
| 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 | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: Procedures - SNOMED CT + Absent/Unknown - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||
| subject | SΣ | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on | ||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| reference | SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||||
| performed[x] | SΣ | 1..1 | When the procedure was performed | |||||||
| performed[x]:All Types | Content/Rules for all Types | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| data-absent-reason | S | 0..1 | code | performed[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing. | ||||||
| performedDateTime | dateTime | |||||||||
| 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(Patient (IPS) | RelatedPerson | Device - performer, observer | Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS)) | The reference to the practitioner | ||||||
| onBehalfOf | 0..1 | Reference(Organization (IPS)) | Organization the device or practitioner was acting for | |||||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||||
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||||
| bodySite | 0..* | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: SNOMEDCTBodyStructures (example) | |||||||
| 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 | |||||||||
| Procedure.language | preferred | CommonLanguages
| |||||||||
| Procedure.status | required | EventStatus | |||||||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | |||||||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | |||||||||
| Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
| Procedure.subject.type | extensible | ResourceType | |||||||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | |||||||||
| Procedure.reasonCode | example | ProcedureReasonCodes | |||||||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures | |||||||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | |||||||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | |||||||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | |||||||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | |||||||||
| Procedure.usedCode | example | FHIRDeviceTypes |
| Id | Grade | Path(s) | Details | Requirements |
| 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() |
This structure is derived from Procedure
Summary
Mandatory: 3 elements
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ Health Level Seven International - Patient Care Work Group. Package hl7.fhir.uv.ips#1.1.0 based on FHIR 4.0.1. Generated 2022-11-22
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