This page is part of the Retrieval of Real World Data for Clinical Research (v1.0.0-ballot: STU1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/fhir/uv/vulcan-rwd/StructureDefinition/ProcedureRwd | Version: 1.0.0-ballot | |||
Active as of 2022-12-04 | Computable Name: ProcedureRwd |
A profile on Procedure that adds MustSupport to outcome.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ProcedureUvIps
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | ProcedureUvIps | An action that is being or was performed on a patient | |
outcome | S | 0..1 | CodeableConcept | The result of procedure |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Procedure | 0..* | ProcedureUvIps | 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 | |||||||||
outcome | SΣ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||||
Documentation for this format |
Path | Conformance | ValueSet | |||||||||
Procedure.status | required | EventStatus | |||||||||
Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) |
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..* | ProcedureUvIps | 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 | SΣ | 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 ProcedureUvIps
Differential View
This structure is derived from ProcedureUvIps
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | ProcedureUvIps | An action that is being or was performed on a patient | |
outcome | S | 0..1 | CodeableConcept | The result of procedure |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Procedure | 0..* | ProcedureUvIps | 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 | |||||||||
outcome | SΣ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||||
Documentation for this format |
Path | Conformance | ValueSet | |||||||||
Procedure.status | required | EventStatus | |||||||||
Procedure.code | preferred | ProceduresSnomedAbsentUnknownUvIps
| |||||||||
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) |
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..* | ProcedureUvIps | 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 | SΣ | 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 ProcedureUvIps
Other representations of profile: CSV, Excel, Schematron