2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile Clinical Quality Framework (CQF) Procedure Request Profile - Definitions

Todo

Definitions for the cqf-procedurerequest-cqf-procedurerequest Profile.

ProcedureRequest(cqf-procedurerequest)
Definition

A request for a procedure to be performed. May be a proposal or an order.

Control1..1
Requirements
Comments
ProcedureRequest.id
Definition

The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.

Control0..1
Typeid
Requirements
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

ProcedureRequest.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Requirements
Comments
ProcedureRequest.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Requirements
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

ProcedureRequest.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Requirements
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource

Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

ProcedureRequest.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Requirements
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

ProcedureRequest.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Requirements
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

ProcedureRequest.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Requirements
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

ProcedureRequest.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Requirements
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

ProcedureRequest.identifier
Definition

Identifiers assigned to this order by the order or by the receiver.

Control0..*
TypeIdentifier
Requirements
Comments
ProcedureRequest.subject
Definition

The patient who will receive the procedure.

Control1..1
TypeReference(Profile = (Profile = http://hl7.org/fhir/Profile/Patient))
Must Supporttrue
Requirements
Comments
ProcedureRequest.type
Definition

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

Control1..1
TypeCodeableConcept
Must Supporttrue
Requirements
Comments
ProcedureRequest.bodySite[x]
Definition

Indicates the site on the subject's body where the procedure should be performed ( i.e. the target site).

Control0..1
TypeChoice of: CodeableConcept, Reference(Profile = (Profile = http://hl7.org/fhir/Profile/BodySite))
Requirements

Knowing where the procedure is made is important for tracking if multiple sites are possible.

Comments

Only used if not implicit in code found in ProcedureRequest.type.

ProcedureRequest.indication
Definition

The reason why the procedure is proposed or ordered. This procedure request may be motivated by a Condition for instance.

Control0..*
TypeCodeableConcept
Must Supporttrue
Requirements
Comments
ProcedureRequest.timing[x]
Definition

The timing schedule for the proposed or ordered procedure. The Schedule data type allows many different expressions, for example. "Every 8 hours"; "Three times a day"; "1/2 an hour before breakfast for 10 days from 23-Dec 2011:"; "15 Oct 2013, 17 Oct 2013 and 1 Nov 2013".

Control0..1
TypeChoice of: dateTime, Period, Timing
Must Supporttrue
Requirements
Comments
ProcedureRequest.encounter
Definition

The encounter within which the procedure proposal or request was created.

Control0..1
TypeReference(Profile = (Profile = http://hl7.org/fhir/Profile/Encounter))
Must Supporttrue
Requirements
Comments
ProcedureRequest.performer
Definition

E.g. surgeon, anaethetist, endoscopist.

Control0..1
TypeChoice of: Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Practitioner)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Organization)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Patient)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/RelatedPerson))
Must Supporttrue
Requirements
Comments
ProcedureRequest.status
Definition

The status of the order.

Control0..1
BindingThe status of the request
The codes SHALL be taken from ProcedureRequestStatus
Typecode
Must Supporttrue
Requirements
Comments
ProcedureRequest.notes
Definition

Any other notes associated with this proposal or order - e.g., provider instructions.

Control0..*
Typestring
Requirements
Comments
ProcedureRequest.asNeeded[x]
Definition

If a CodeableConcept is present, it indicates the pre-condition for performing the procedure.

Control0..1
TypeChoice of: boolean, CodeableConcept
Must Supporttrue
Requirements
Comments
ProcedureRequest.orderedOn
Definition

The time when the request was made.

Control0..1
TypedateTime
Must Supporttrue
Requirements
Comments
ProcedureRequest.orderer
Definition

The healthcare professional responsible for proposing or ordering the procedure.

Control0..1
TypeChoice of: Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Practitioner)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Patient)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/RelatedPerson)), Reference(Profile = (Profile = http://hl7.org/fhir/Profile/Device))
Must Supporttrue
Requirements
Comments
ProcedureRequest.priority
Definition

The clinical priority associated with this order.

Control0..1
BindingThe priority of the request
The codes SHALL be taken from ProcedureRequestPriority
Typecode
Must Supporttrue
Requirements
Comments