Retrieval of Real World Data for Clinical Research
1.0.0 - trial-use
Retrieval of Real World Data for Clinical Research
1.0.0 - trial-use
This page is part of the Retrieval of Real World Data for Clinical Research (v1.0.0: STU1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/uv/vulcan-rwd/StructureDefinition/ProcedureRwd | Version: 1.0.0 | |||
| Active as of 2023-05-26 | Computable Name: ProcedureRwd | |||
A profile on Procedure that indicates the minimum set of attributes required for detailing a patient’s procedures.
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 | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
| code | S | 0..1 | CodeableConcept | Identification of the procedure |
 subject | S | 1..1 | Reference(IPA-Patient) | Who the procedure was performed on |
| performed[x] | S | 0..1 | dateTime, Period, string, Age, Range | When the procedure was performed |
 outcome | S | 0..1 | CodeableConcept | The result of procedure |
| Documentation for this format | ||||
| 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 | ?!SΣ | 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 | SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject | SΣ | 1..1 | Reference(IPA-Patient) | Who the procedure was performed on |
  performed[x] | SΣ | 0..1 | When the procedure was performed | |
 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 | example | ProcedureCodes(SNOMEDCT) |
| 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..* | 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 | ?!SΣ | 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 | SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject | SΣ | 1..1 | Reference(IPA-Patient) | Who the procedure was performed on | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣ | 0..1 | When the procedure was performed | |||||
| 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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | Σ | 0..* | CodeableConcept | 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 (example): Codes describing anatomical locations. May include laterality. | ||||
| 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 | example | ProcedureCodes(SNOMEDCT) | ||||
| 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
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 | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
| code | S | 0..1 | CodeableConcept | Identification of the procedure |
| subject | S | 1..1 | Reference(IPA-Patient) | Who the procedure was performed on |
| performed[x] | S | 0..1 | dateTime, Period, string, Age, Range | When the procedure was performed |
| outcome | S | 0..1 | CodeableConcept | The result of procedure |
| Documentation for this format | ||||
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 | ?!SΣ | 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 | SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject | SΣ | 1..1 | Reference(IPA-Patient) | Who the procedure was performed on |
| performed[x] | SΣ | 0..1 | When the procedure was performed | |
| 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 | example | ProcedureCodes(SNOMEDCT) |
| 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..* | 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 | ?!SΣ | 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 | SΣ | 0..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject | SΣ | 1..1 | Reference(IPA-Patient) | Who the procedure was performed on | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣ | 0..1 | When the procedure was performed | |||||
| 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(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | Σ | 0..* | CodeableConcept | 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 (example): Codes describing anatomical locations. May include laterality. | ||||
| 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 | example | ProcedureCodes(SNOMEDCT) | ||||
| 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
Other representations of profile: CSV, Excel, Schematron
IG © 2022+ HL7 International - Biomedical Research & Regulation Work Group. Package hl7.fhir.uv.vulcan-rwd#1.0.0 based on FHIR 4.0.1. Generated 2023-05-26
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