International Patient Summary Implementation Guide
2.0.0 - STU 2
International Patient Summary Implementation Guide
2.0.0 - STU 2
This page is part of the International Patient Summary Implementation Guide (v2.0.0: STU 2) 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
| Official URL: http://hl7.org/fhir/uv/ips/StructureDefinition/Procedure-uv-ips | Version: 2.0.0 | |||
| Standards status: Trial-use | Maturity Level: 3 | 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.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
  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 |
SOΣ | 1..1 | CodeableConceptIPS | Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||||
  subject |
SOΣ | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on
| ||||||||
  reference |
SOΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL
| ||||||||
 Slices for performed[x] |
SOΣ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this
| |||||||||
 performedDateTime |
dateTime | |||||||||||
| performedPeriod |
Period | |||||||||||
| performedString |
string | |||||||||||
| performedAge |
Age | |||||||||||
| performedRange |
Range | |||||||||||
  performed[x]:performedDateTime |
SOΣ | 0..1 | dateTime | When the procedure was performed
| ||||||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | preferred | Procedures - IPS | 📦2.0.0 | This IG |
| Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
This structure is derived from Procedure
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.code | Base | preferred | Procedures - IPS | 📦2.0.0 | This IG |
| Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std. |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||
| 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 |
SOΣ | 1..1 | CodeableConceptIPS | Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||||
| subject |
SOΣ | 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 |
SOΣC | 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 | ||||||||
| Slices for performed[x] |
SOΣ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this
| |||||||||
| performedDateTime |
dateTime | |||||||||||
| performedPeriod |
Period | |||||||||||
| performedString |
string | |||||||||||
| performedAge |
Age | |||||||||||
| performedRange |
Range | |||||||||||
| performed[x]:performedDateTime |
SOΣ | 0..1 | dateTime | When the procedure was performed
| ||||||||
| 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 or Observer (IPS) | 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 |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) | ||||||||
| 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 | Status | Usage | ValueSet | Version | Source |
| Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std. |
| Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | preferred | Procedures - IPS | 📦2.0.0 | This IG |
| Procedure.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Procedure.performer.function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std. |
| Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std. |
| Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std. |
| Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📍4.0.1 | FHIR Std. |
| Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
This structure is derived from Procedure
Summary
Mandatory: 3 elements
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
SOΣ | 1..1 | CodeableConceptIPS | Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||||
| subject |
SOΣ | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on
| ||||||||
| reference |
SOΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL
| ||||||||
| Slices for performed[x] |
SOΣ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this
| |||||||||
| performedDateTime |
dateTime | |||||||||||
| performedPeriod |
Period | |||||||||||
| performedString |
string | |||||||||||
| performedAge |
Age | |||||||||||
| performedRange |
Range | |||||||||||
| performed[x]:performedDateTime |
SOΣ | 0..1 | dateTime | When the procedure was performed
| ||||||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) | ||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | preferred | Procedures - IPS | 📦2.0.0 | This IG |
| Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Procedure |
Procedure | |||||||||||
| code |
SO | 1..1 | CodeableConceptIPS | Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||||
| subject |
SO | 1..1 | Reference(Patient (IPS)) | Who the procedure was performed on
| ||||||||
 reference |
SO | 1..1 | string | Literal reference, Relative, internal or absolute URL
| ||||||||
| Slices for performed[x] |
SO | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed Slice: Unordered, Open by type:$this
| ||||||||
| performed[x]:performedDateTime |
SO | 0..1 | dateTime | When the procedure was performed
| ||||||||
| performer |
||||||||||||
| actor |
1..1 | Reference(Patient (IPS) | RelatedPerson | Device - Performer or Observer (IPS) | 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..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) | |||||||||
| Documentation for this format | ||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.code | Base | preferred | Procedures - IPS | 📦2.0.0 | This IG |
| Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std. |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||
| 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 |
SOΣ | 1..1 | CodeableConceptIPS | Identification of the procedure Binding: Procedures - IPS (preferred): SNOMED CT procedure code set or a code for absent/unknown procedure
| ||||||||
| subject |
SOΣ | 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 |
SOΣC | 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 | ||||||||
| Slices for performed[x] |
SOΣ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this
| |||||||||
| performedDateTime |
dateTime | |||||||||||
| performedPeriod |
Period | |||||||||||
| performedString |
string | |||||||||||
| performedAge |
Age | |||||||||||
| performedRange |
Range | |||||||||||
| performed[x]:performedDateTime |
SOΣ | 0..1 | dateTime | When the procedure was performed
| ||||||||
| 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 or Observer (IPS) | 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 |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (preferred) | ||||||||
| 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 | Status | Usage | ValueSet | Version | Source |
| Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | example | Procedure Not Performed Reason (SNOMED-CT) | 📍4.0.1 | FHIR Std. |
| Procedure.category | Base | example | Procedure Category Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.code | Base | preferred | Procedures - IPS | 📦2.0.0 | This IG |
| Procedure.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Procedure.performer.function | Base | example | Procedure Performer Role Codes | 📍4.0.1 | FHIR Std. |
| Procedure.reasonCode | Base | example | Procedure Reason Codes | 📍4.0.1 | FHIR Std. |
| Procedure.bodySite | Base | preferred | SNOMED CT Body Structures | 📦4.0.1 | FHIR Std. |
| Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std. |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std. |
| Procedure.focalDevice.action | Base | preferred | Procedure Device Action Codes | 📍4.0.1 | FHIR Std. |
| Procedure.usedCode | Base | example | FHIR Device Types | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
This structure is derived from Procedure
Summary
Mandatory: 3 elements
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Patient Care. Package hl7.fhir.uv.ips#2.0.0 based on FHIR 4.0.1. Generated 2025-10-03
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