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4.6 Resource Procedure - Content

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

4.6.1 Scope and Usage

This resource is used to record the details of procedures performed on a patient. A procedure is an activity that is performed with or on a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, and exclude things for which there are specific resources, such as immunizations, drug administrations.

Note that many diagnostic processes are procedures that generate observations and reports. In many cases, the existence of the procedure is assumed, but where there are details of interest about how the diagnostic procedure was performed, the procedure resource is used to describe the activity.

4.6.2 Resource Content

Procedure (Resource)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)identifier : Identifier 0..*The person on whom the procedure was performedsubject : Resource(Patient) 1..1The specific procedure that is performed. Use text if the exact nature of the procedure can't be codedtype : CodeableConcept 1..1Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesionbodySite : CodeableConcept 0..*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 textindication : CodeableConcept 0..*The dates over which the procedure was performed. Allows a period to support complex procedures that span more that one date, and also allows for the length of the procedure to be captureddate : Period 0..1The encounter during which the procedure was performedencounter : Resource(Encounter) 0..1What was the outcome of the procedure - did it resolve reasons why the procedure was performed?outcome : string 0..1This could be a histology result. There could potentially be multiple reports - e.g. if this was a procedure that made multiple biopsiesreport : Resource(DiagnosticReport) 0..*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' issuescomplication : CodeableConcept 0..*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 usedfollowUp : string 0..1Any other notes about the procedure - e.g. the operative notesnotes : string 0..1PerformerThe practitioner who was involved in the procedureperson : Resource(Practitioner) 0..1E.g. surgeon, anaethetist, endoscopistrole : CodeableConcept 0..1RelatedItemThe nature of the relationshiptype : code 0..1 <<The nature of the relationship with this procedureProcedureRelationshipType>>The related item - e.g. a proceduretarget : Resource(AdverseReaction| AllergyIntolerance|CarePlan|Condition| DeviceObservationReport|DiagnosticReport| FamilyHistory|ImagingStudy|Immunization| ImmunizationRecommendation| MedicationAdministration| MedicationDispense| MedicationPrescription| MedicationStatement|Observation| Procedure) 0..1Limited to 'real' people rather than equipmentperformer0..*Procedures may be related to other items such as procedures or medications. For example treating wound dehiscence following a previous procedurerelatedItem0..*

This resource is referenced by CarePlan and Condition

<Procedure xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: extension, modifierExtension, language, text, and contained -->
 <identifier><!-- 0..* Identifier External Ids for this procedure § --></identifier>
 <subject><!-- 1..1 Resource(Patient) Who procedure was performed on § --></subject>
 <type><!-- 1..1 CodeableConcept Identification of the procedure § --></type>
 <bodySite><!-- 0..* CodeableConcept Precise location details § --></bodySite>
 <indication><!-- 0..* CodeableConcept Reason procedure performed § --></indication>
 <performer>  <!-- 0..* The people who performed the procedure § -->
  <person><!-- 0..1 Resource(Practitioner) The reference to the practitioner § --></person>
  <role><!-- 0..1 CodeableConcept The role the person was in § --></role>
 </performer>
 <date><!-- 0..1 Period The date the procedure was performed § --></date>
 <encounter><!-- 0..1 Resource(Encounter) The encounter when procedure performed § --></encounter>
 <outcome value="[string]"/><!-- 0..1 What was result of procedure? § -->
 <report><!-- 0..* Resource(DiagnosticReport) Any report that results from the procedure --></report>
 <complication><!-- 0..* CodeableConcept Complication following the procedure --></complication>
 <followUp value="[string]"/><!-- 0..1 Instructions for follow up -->
 <relatedItem>  <!-- 0..* A procedure that is related to this one -->
  <type value="[code]"/><!-- 0..1 caused-by | because-of -->
  <target><!-- 0..1 Resource(AdverseReaction|AllergyIntolerance|CarePlan|
    Condition|DeviceObservationReport|DiagnosticReport|FamilyHistory|
    ImagingStudy|Immunization|ImmunizationRecommendation|
    MedicationAdministration|MedicationDispense|MedicationPrescription|
    MedicationStatement|Observation|Procedure) The related item - e.g. a procedure --></target>
 </relatedItem>
 <notes value="[string]"/><!-- 0..1 Additional information about procedure -->
</Procedure>

Alternate definitions: Schema/Schematron, Resource Profile

4.6.2.1 Terminology Bindings

PathDefinitionTypeReference
Procedure.relatedItem.type The nature of the relationship with this procedureFixedhttp://hl7.org/fhir/procedure-relationship-type

4.6.3 Search Parameters

Search parameters for this resource. The standard parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
_idtokenThe logical resource id associated with the resource (must be supported by all servers)
_languagetokenThe language of the resource
datedateThe date the procedure was performed onProcedure.date
subjectreferenceThe identity of a patient to list procedures forProcedure.subject
(Patient)
typetokenType of procedureProcedure.type
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