Birth And Fetal Death (BFDR) FHIR Implementation Guide
2.0.0 - STU2
Birth And Fetal Death (BFDR) FHIR Implementation Guide
2.0.0 - STU2
This page is part of the Vital Records Birth and Fetal Death Reporting (v2.0.0: STU2) based on FHIR (HL7® FHIR® Standard) 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/us/bfdr/StructureDefinition/Procedure-obstetric | Version: 2.0.0 | |||
| Active as of 2024-10-15 | Computable Name: ProcedureObstetric | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.13.42.97 | ||||
This profile represents information about a particular medical treatment or invasive/manipulative procedure that was performed during this pregnancy specifically in the treatment of the pregnancy, management of labor and/or delivery.
| Use Case | # | Description | IJE Name | Field | Type | Value Set/Comments |
|---|---|---|---|---|---|---|
| Natality | 176 | Obstetric Procedures--Successful External Cephalic Version | ECVS | code=240278000 (External cephalic version (procedure)), outcome=385669000 (Successful (qualifier value)) |
codeable | |
| Natality | 177 | Obstetric Procedures--Failed External Cephalic Version | ECVF | code=240278000 (External cephalic version (procedure)), outcome=385671000 (Unsuccessful (qualifier value)) |
codeable |
| Item # | Form Field | FHIR Profile Field | Reference |
|---|---|---|---|
| 43 | Obstetric Procedures | - | Certificate of Live Birth |
| 16 | Obstetric procedures | - | Facility Worksheet for the Live Birth Certificate |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure |
USCoreProcedureProfile | |||
  category |
1..1 | CodeableConcept | Obstetric procedures performed [US Standard Certificate of Live Birth] Required Pattern: At least the following | |
   coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
  system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
 code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 73814-6 | |
| code |
1..1 | CodeableConcept | External cephalic version (procedure) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 240278000 | |
 subject |
1..1 | Reference(Patient - Mother Vital Records) | Who the procedure was performed on | |
| outcome |
0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: Obstetric Procedure Outcome (required): Subset of ProcedureOutcomeCodes(SNOMEDCT) including successful or unsuccessful | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.outcome | required | ObstetricProcedureOutcomeVShttp://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-obstetric-procedure-outcomefrom this IG |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
 category |
Σ | 1..1 | CodeableConcept | Obstetric procedures performed [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 73814-6 | |
| code |
SΣ | 1..1 | CodeableConcept | External cephalic version (procedure) Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 240278000 | |
| subject |
SΣ | 1..1 | Reference(Patient - Mother Vital Records) | Who the procedure was performed on |
 performed[x] |
SΣC | 0..1 | When the procedure was performed | |
| performedDateTime |
dateTime | |||
| outcome |
Σ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: Obstetric Procedure Outcome (required): Subset of ProcedureOutcomeCodes(SNOMEDCT) including successful or unsuccessful |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | |
| Procedure.category | example | Pattern: LOINC Code 73814-6http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | |
| Procedure.code | extensible | Pattern: SNOMED-CT Code 240278000http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.outcome | required | ObstetricProcedureOutcomeVShttp://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-obstetric-procedure-outcomefrom this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' | ||||
| 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 |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| 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 | 1..1 | CodeableConcept | Obstetric procedures performed [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 73814-6 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | External cephalic version (procedure) Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 240278000 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
SΣ | 1..1 | Reference(Patient - Mother Vital Records) | Who the procedure was performed on | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] |
SΣC | 0..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime S | |||||||
| 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 |
Σ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: Obstetric Procedure Outcome (required): Subset of ProcedureOutcomeCodes(SNOMEDCT) including successful or unsuccessful | ||||
| 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 / Code | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | Pattern: LOINC Code 73814-6http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | Pattern: SNOMED-CT Code 240278000http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | required | ObstetricProcedureOutcomeVShttp://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-obstetric-procedure-outcomefrom this IG | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
This structure is derived from USCoreProcedureProfile
Differential View
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
USCoreProcedureProfile | |||
| category |
1..1 | CodeableConcept | Obstetric procedures performed [US Standard Certificate of Live Birth] Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 73814-6 | |
| code |
1..1 | CodeableConcept | External cephalic version (procedure) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 240278000 | |
| subject |
1..1 | Reference(Patient - Mother Vital Records) | Who the procedure was performed on | |
| outcome |
0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: Obstetric Procedure Outcome (required): Subset of ProcedureOutcomeCodes(SNOMEDCT) including successful or unsuccessful | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.outcome | required | ObstetricProcedureOutcomeVShttp://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-obstetric-procedure-outcomefrom this IG |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| category |
Σ | 1..1 | CodeableConcept | Obstetric procedures performed [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 73814-6 | |
| code |
SΣ | 1..1 | CodeableConcept | External cephalic version (procedure) Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 240278000 | |
| subject |
SΣ | 1..1 | Reference(Patient - Mother Vital Records) | Who the procedure was performed on |
| performed[x] |
SΣC | 0..1 | When the procedure was performed | |
| performedDateTime |
dateTime | |||
| outcome |
Σ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: Obstetric Procedure Outcome (required): Subset of ProcedureOutcomeCodes(SNOMEDCT) including successful or unsuccessful |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | |
| Procedure.category | example | Pattern: LOINC Code 73814-6http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | |
| Procedure.code | extensible | Pattern: SNOMED-CT Code 240278000http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.outcome | required | ObstetricProcedureOutcomeVShttp://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-obstetric-procedure-outcomefrom this IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' | ||||
| 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 |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| 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 | 1..1 | CodeableConcept | Obstetric procedures performed [US Standard Certificate of Live Birth] Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 73814-6 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | External cephalic version (procedure) Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 240278000 | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| subject |
SΣ | 1..1 | Reference(Patient - Mother Vital Records) | Who the procedure was performed on | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] |
SΣC | 0..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime S | |||||||
| 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 |
Σ | 0..1 | CodeableConcept | Outcome, if procedure was performed. Binding: Obstetric Procedure Outcome (required): Subset of ProcedureOutcomeCodes(SNOMEDCT) including successful or unsuccessful | ||||
| 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 / Code | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | Pattern: LOINC Code 73814-6http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | Pattern: SNOMED-CT Code 240278000http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | required | ObstetricProcedureOutcomeVShttp://hl7.org/fhir/us/bfdr/ValueSet/ValueSet-obstetric-procedure-outcomefrom this IG | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
This structure is derived from USCoreProcedureProfile
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 International / Public Health. Package hl7.fhir.us.bfdr#2.0.0 based on FHIR 4.0.1. Generated 2024-10-15
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change