Womens Health Technology Coordinated Registry Network Implementation Guide For Comment Ballot

This page is part of the Womens Health Technology Coordinated Registry Network FHIR IG (v0.1.0: STU 1 Draft) based on FHIR v3.5.0. . For a full list of available versions, see the Directory of published versions

StructureDefinition-procedure-crn

source file: source/pages/_includes/procedure-crn-intro.md

Scope and Usage

The profile is to be used for the WTH CRN project to capture the specific procedure information performed on the patient.

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). blah blah blah

must have:

  1. status
  2. patient

Additional Profile specific implementation guidance:

Examples

  • Examples to be added after finalization of data elements.

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/womens-health-registries/StructureDefinition/procedure-crn

Published on Wed Feb 15 00:00:00 AEST 2017 as a active by .

This profile builds on Procedure


Summary

Mandatory: 2 elements (1 nested mandatory element)
Must-Support: 13 elements

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*An action that is being or was performed on a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf SΣ0..*Reference(Procedure)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown
Binding: EventStatus (required)
... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example)
... category SΣ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example)
... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: ProcedureCodes(SNOMEDCT) (example)
... subject SΣ1..1Reference(Patient)Who the procedure was performed on
... context SΣ0..1Reference(Encounter)Encounter or episode associated with the procedure
... performed[x] SΣ0..1dateTime, Period, string, Age, RangeWhen the procedure was performed
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer SΣI0..*BackboneElementThe people who performed the procedure
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example)
.... actor SΣ1..1Reference(Practitioner)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode SΣ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example)
... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite SΣ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example)
... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example)
... report 0..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example)
... complicationDetail 0..*Reference(Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example)
... note 0..*AnnotationAdditional information about the procedure
... focalDevice SI0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred)
.... manipulated 1..1Reference(Device)Device that was changed
... usedReference S0..*Reference(Device)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example)

doco Documentation for this format

       // 
 {
   "resourceType" : "Procedure",
    "id" : "<id>", // Logical id of this artifact
    "meta" : {Meta}, // Metadata about the resource
    "implicitRules" : "<uri>", // A set of rules under which this content was created
    "language" : "<code>", // Language of the resource content
    "text" : {Narrative}, // Text summary of the resource, for human interpretation
    "contained" : [{Resource}], // Contained, inline Resources
    "extension": [
    ],
    "identifier" : [{Identifier}], // External Identifiers for this procedure
    "instantiatesCanonical" : ["<canonical>"], // Instantiates FHIR protocol or definition
    "instantiatesUri" : ["<uri>"], // Instantiates external protocol or definition
    "basedOn" : [{Reference(CarePlan)}], // A request for this procedure
    "partOf" : [{Reference(Procedure)}], // Part of referenced event
    "status" : "<code>", // R! preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown
    "statusReason" : {CodeableConcept}, // Reason for current status
    "category" : {CodeableConcept}, // Classification of the procedure
    "code" : {CodeableConcept}, // Identification of the procedure
    "subject" : {Reference(Patient)}, // R! Who the procedure was performed on
    "context" : {Reference(Encounter)}, // Encounter or episode associated with the procedure
// performed[x]: When the procedure was performed. One of these 5:
    "performedDateTime" : "<dateTime>", // When the procedure was performed
    "performedPeriod" : {Period}, // When the procedure was performed
    "performedString" : "<string>", // When the procedure was performed
    "performedAge" : {Age}, // When the procedure was performed
    "performedRange" : {Range}, // When the procedure was performed
    "recorder" : {Reference(Patient)}, // Who recorded the procedure
    "asserter" : {Reference(Patient)}, // Person who asserts this procedure
    "performer" : [{ // C? The people who performed the procedure
      "extension": [
      ],
      "function" : {CodeableConcept}, // Type of performance
      "actor" : {Reference(Practitioner)}, // R! The reference to the practitioner
      "onBehalfOf" : {Reference(Organization)}, // Organization the device or practitioner was acting for
    }],
    "location" : {Reference(Location)}, // Where the procedure happened
    "reasonCode" : [{CodeableConcept}], // Coded reason procedure performed
    "reasonReference" : [{Reference(Condition)}], // The justification that the procedure was performed
    "bodySite" : [{CodeableConcept}], // Target body sites
    "outcome" : {CodeableConcept}, // The result of procedure
    "report" : [{Reference(DiagnosticReport)}], // Any report resulting from the procedure
    "complication" : [{CodeableConcept}], // Complication following the procedure
    "complicationDetail" : [{Reference(Condition)}], // A condition that is a result of the procedure
    "followUp" : [{CodeableConcept}], // Instructions for follow up
    "note" : [{Annotation}] // Additional information about the procedure
    "focalDevice" : [{ // C? Manipulated, implanted, or removed device
      "extension": [
      ],
      "action" : {CodeableConcept}, // Kind of change to device
      "manipulated" : {Reference(Device)}, // R! Device that was changed
    }],
    "usedReference" : [{Reference(Device)}], // Items used during procedure
    "usedCode" : [{CodeableConcept}], // Coded items used during the procedure
  }

     

Summary

Mandatory: 2 elements (1 nested mandatory element)
Must-Support: 13 elements

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*An action that is being or was performed on a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf SΣ0..*Reference(Procedure)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown
Binding: EventStatus (required)
... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example)
... category SΣ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example)
... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: ProcedureCodes(SNOMEDCT) (example)
... subject SΣ1..1Reference(Patient)Who the procedure was performed on
... context SΣ0..1Reference(Encounter)Encounter or episode associated with the procedure
... performed[x] SΣ0..1dateTime, Period, string, Age, RangeWhen the procedure was performed
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer SΣI0..*BackboneElementThe people who performed the procedure
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example)
.... actor SΣ1..1Reference(Practitioner)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode SΣ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example)
... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite SΣ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example)
... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example)
... report 0..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example)
... complicationDetail 0..*Reference(Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example)
... note 0..*AnnotationAdditional information about the procedure
... focalDevice SI0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred)
.... manipulated 1..1Reference(Device)Device that was changed
... usedReference S0..*Reference(Device)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example)

doco Documentation for this format

JSON Template


          // 
 {
   "resourceType" : "Procedure",
    "id" : "<id>", // Logical id of this artifact
    "meta" : {Meta}, // Metadata about the resource
    "implicitRules" : "<uri>", // A set of rules under which this content was created
    "language" : "<code>", // Language of the resource content
    "text" : {Narrative}, // Text summary of the resource, for human interpretation
    "contained" : [{Resource}], // Contained, inline Resources
    "extension": [
    ],
    "identifier" : [{Identifier}], // External Identifiers for this procedure
    "instantiatesCanonical" : ["<canonical>"], // Instantiates FHIR protocol or definition
    "instantiatesUri" : ["<uri>"], // Instantiates external protocol or definition
    "basedOn" : [{Reference(CarePlan)}], // A request for this procedure
    "partOf" : [{Reference(Procedure)}], // Part of referenced event
    "status" : "<code>", // R! preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown
    "statusReason" : {CodeableConcept}, // Reason for current status
    "category" : {CodeableConcept}, // Classification of the procedure
    "code" : {CodeableConcept}, // Identification of the procedure
    "subject" : {Reference(Patient)}, // R! Who the procedure was performed on
    "context" : {Reference(Encounter)}, // Encounter or episode associated with the procedure
// performed[x]: When the procedure was performed. One of these 5:
    "performedDateTime" : "<dateTime>", // When the procedure was performed
    "performedPeriod" : {Period}, // When the procedure was performed
    "performedString" : "<string>", // When the procedure was performed
    "performedAge" : {Age}, // When the procedure was performed
    "performedRange" : {Range}, // When the procedure was performed
    "recorder" : {Reference(Patient)}, // Who recorded the procedure
    "asserter" : {Reference(Patient)}, // Person who asserts this procedure
    "performer" : [{ // C? The people who performed the procedure
      "extension": [
      ],
      "function" : {CodeableConcept}, // Type of performance
      "actor" : {Reference(Practitioner)}, // R! The reference to the practitioner
      "onBehalfOf" : {Reference(Organization)}, // Organization the device or practitioner was acting for
    }],
    "location" : {Reference(Location)}, // Where the procedure happened
    "reasonCode" : [{CodeableConcept}], // Coded reason procedure performed
    "reasonReference" : [{Reference(Condition)}], // The justification that the procedure was performed
    "bodySite" : [{CodeableConcept}], // Target body sites
    "outcome" : {CodeableConcept}, // The result of procedure
    "report" : [{Reference(DiagnosticReport)}], // Any report resulting from the procedure
    "complication" : [{CodeableConcept}], // Complication following the procedure
    "complicationDetail" : [{Reference(Condition)}], // A condition that is a result of the procedure
    "followUp" : [{CodeableConcept}], // Instructions for follow up
    "note" : [{Annotation}] // Additional information about the procedure
    "focalDevice" : [{ // C? Manipulated, implanted, or removed device
      "extension": [
      ],
      "action" : {CodeableConcept}, // Kind of change to device
      "manipulated" : {Reference(Device)}, // R! Device that was changed
    }],
    "usedReference" : [{Reference(Device)}], // Items used during procedure
    "usedCode" : [{CodeableConcept}], // Coded items used during the procedure
  }

        

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

Search Requirements

There are no specific search requirements by the WHT CRN IG beyond what is required by the base resource.