QI-Core Implementation Guide: STU Ballot (v3.3.0 for FHIR 4.0.0)
Quality Improvement Core Framework (v3.3.0: STU 4 Ballot 1). The current version is 3.2.0 based on FHIR R4. See the Directory of published versions
| Appendectomy Example |
The official URL for this profile is:
http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
Profile of Procedure for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
This profile builds on USCoreProcedureProfile.
This profile was published on Wed Aug 22 00:00:00 EDT 2018 as a draft by Health Level Seven, Inc. - CQI WG.
Description of Profiles, Differentials, and Snapshots.
Summary
Mandatory: 2 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | I | 0..* | 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) Max Binding: AllLanguages | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
 contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| procedure-approachBodyStructure | I | 0..* | Reference(BodyStructure) | The access point or points used for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-approachBodyStructure |
| procedure-incisionDateTime | I | 0..1 | dateTime | The first incision time URL: http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime |
 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 | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) |
| code | SΣ | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (preferred) |
| subject | SΣ | 1..1 | Reference(QICorePatient) | Who the procedure was performed on |
| encounter | SΣ | 0..1 | Reference(QICoreEncounter | Group) | Encounter created as part of |
 performed[x] | SΣ | 1..1 | When the procedure was performed | |
 performedDateTime | dateTime | |||
 performedPeriod | Period | |||
| 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 | SΣI | 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) |
| actor | Σ | 1..1 | Reference(QICorePractitioner | QICoreOrganization | QICorePatient | QICoreRelatedPerson) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(QICoreLocation) | Where the procedure happened |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example) |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example) |
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
| report | S | 0..* | Reference(QICoreDiagnosticReportNote) | Any report resulting from the procedure |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | I | 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) | |
| manipulated | 1..1 | Reference(QICoreDevice) | 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) | |
| Documentation for this format | ||||
Summary
Mandatory: 2 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | I | 0..* | 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) Max Binding: AllLanguages | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| procedure-approachBodyStructure | I | 0..* | Reference(BodyStructure) | The access point or points used for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-approachBodyStructure |
| procedure-incisionDateTime | I | 0..1 | dateTime | The first incision time URL: http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime |
| 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 | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) |
| code | SΣ | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (preferred) |
| subject | SΣ | 1..1 | Reference(QICorePatient) | Who the procedure was performed on |
| encounter | SΣ | 0..1 | Reference(QICoreEncounter | Group) | Encounter created as part of |
| performed[x] | SΣ | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| 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 | SΣI | 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) |
| actor | Σ | 1..1 | Reference(QICorePractitioner | QICoreOrganization | QICorePatient | QICoreRelatedPerson) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(QICoreLocation) | Where the procedure happened |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example) |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example) |
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
| report | S | 0..* | Reference(QICoreDiagnosticReportNote) | Any report resulting from the procedure |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | I | 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) | |
| manipulated | 1..1 | Reference(QICoreDevice) | 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) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Procedure.status | required | EventStatus |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) |
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) |
| Procedure.code | preferred | USCoreProcedureCodes |
| 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 | Path | Details | Requirements |
| dom-2 | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-4 | 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-3 | 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-6 | Procedure | A resource should have narrative for robust management : text.div.exists() | |
| dom-5 | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | Procedure.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | Procedure.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | Procedure.focalDevice | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
© HL7.org 2011+. (Clinical Quality Improvement WG). hl7.fhir.us.qicore#3.3.0 based on FHIR v4.0.0 generated 06/08/2019.
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