An action that is or was performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counseling or hypnotherapy.

This records identifiers associated with this procedure that are defined by business processed and/ or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Need to allow connection to a wider workflow.

The person on whom the procedure was performed.

A code specifying the state of the procedure record. Generally this will be in-progress or completed state.

A code that classifies the procedure for searching, sorting and display purposes.

The specific procedure that is performed. Use text if the exact nature of the procedure can't be coded.

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapuetic.

Limited to 'real' people rather than equipment.

The practitioner who was involved in the procedure.

E.g. surgeon, anaethetist, endoscopist.

The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

The encounter during which the procedure was performed.

The location where the procedure actually happened. e.g. a newborn at home, a tracheostomy at a restaurant.

Ties a procedure to where the records are kept.

What was the outcome of the procedure - did it resolve reasons why the procedure was performed?

This could be a histology result. There could potentially be multiple reports - e.g. if this was a procedure that made multiple biopsies.

Any complications that occurred during the procedure, or in the immediate post-operative period. These are generally tracked separately from the notes, which typically will describe the procedure itself rather than any 'post procedure' issues.

If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or potentially could be more complex in which case the CarePlan resource can be used.

Procedures may be related to other items such as procedures or medications. For example treating wound dehiscence following a previous procedure.

The nature of the relationship.

The related item - e.g. a procedure.

Any other notes about the procedure - e.g. the operative notes.

A device change during the procedure.

The kind of change that happened to the device during the procedure.

The device that was manipulated (changed) during the procedure.

Identifies medications, devices and other substance used as part of the procedure.

Used for tracking contamination, etc.

For devices actually implanted or removed, use Procedure.device.