STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 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 . Page versions: R5 R4B R4 R3 R2

Detailed Descriptions for the elements in the Procedure resource.

Procedure
Definition

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

Control1..1
InvariantsDefined on this element
pro-1: Reason not performed is only permitted if notPerformed indicator is true (expression : reasonNotPerformed.empty() or notPerformed = true, xpath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true())
Procedure.identifier
Definition

This records identifiers associated with this procedure that are defined by business processes 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).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Summarytrue
Procedure.status
Definition

A code specifying the state of the procedure. Generally this will be in-progress or completed state.

Control1..1
Terminology BindingProcedureStatus (Required)
Typecode
Is Modifiertrue
Summarytrue
Comments

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

Procedure.category
Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Control0..1
Terminology BindingProcedure Category Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Procedure.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Control1..1
Terminology BindingProcedure Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Procedure.subject
Definition

The person, animal or group on which the procedure was performed.

Control1..1
TypeReference(Patient | Group)
Summarytrue
Procedure.encounter
Definition

The encounter during which the procedure was performed.

Control0..1
TypeReference(Encounter)
Summarytrue
Procedure.performed[x]
Definition

The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Control0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Procedure.performer
Definition

Limited to 'real' people rather than equipment.

Control0..*
Summarytrue
Procedure.performer.actor
Definition

The practitioner who was involved in the procedure.

Control0..1
TypeReference(Practitioner | Organization | Patient | RelatedPerson)
Summarytrue
Procedure.performer.role
Definition

For example: surgeon, anaethetist, endoscopist.

Control0..1
Terminology BindingProcedure Performer Role Codes (Example)
TypeCodeableConcept
Summarytrue
Procedure.location
Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Control0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Summarytrue
Procedure.reasonReference
Definition

The condition that is the reason why the procedure was performed.

Control0..*
TypeReference(Condition)
Summarytrue
Comments

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.

Procedure.reasonCode
Definition

The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text.

Control0..*
Terminology BindingProcedure Reason Codes (Example)
TypeCodeableConcept
Summarytrue
Procedure.notPerformed
Definition

Set this to true if the record is saying that the procedure was NOT performed.

Control0..1
Typeboolean
Is Modifiertrue
Default Valuefalse
Summarytrue
Comments

If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome.

Procedure.reasonNotPerformed
Definition

A code indicating why the procedure was not performed.

Control0..*
Terminology BindingProcedure Not Performed Reason (SNOMED-CT) (Example)
TypeCodeableConcept
InvariantsAffect this element
pro-1: Reason not performed is only permitted if notPerformed indicator is true (expression : reasonNotPerformed.empty() or notPerformed = true, xpath: not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true())
Procedure.bodySite
Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Control0..*
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summarytrue
To DoIs this approach or target site? RIM mapping inconsistent with ProcedureRequest which lists target site. Recommend calling field targetBodySite or targetSite.
Procedure.outcome
Definition

The outcome of the procedure - did it resolve reasons for the procedure being performed?

Control0..1
Terminology BindingProcedure Outcome Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Procedure.report
Definition

This could be a histology result, pathology report, surgical report, etc..

Control0..*
TypeReference(DiagnosticReport)
Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Procedure.complication
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Control0..*
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

To DoNeed harmonization proposal for new ActRelationshipType code.
Procedure.followUp
Definition

If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.

Control0..*
Terminology BindingProcedure Follow up Codes (SNOMED CT) (Example)
TypeCodeableConcept
Procedure.request
Definition

A reference to a resource that contains details of the request for this procedure.

Control0..1
TypeReference(CarePlan | DiagnosticRequest | ProcedureRequest | ReferralRequest)
Procedure.notes
Definition

Any other notes about the procedure. E.g. the operative notes.

Control0..*
TypeAnnotation
Procedure.focalDevice
Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Control0..*
Procedure.focalDevice.action
Definition

The kind of change that happened to the device during the procedure.

Control0..1
Terminology BindingProcedure Device Action Codes (Required)
TypeCodeableConcept
Procedure.focalDevice.manipulated
Definition

The device that was manipulated (changed) during the procedure.

Control1..1
TypeReference(Device)
Procedure.usedReference
Definition

Identifies medications, devices and any other substance used as part of the procedure.

Control0..*
TypeReference(Device | Medication | Substance)
Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.

Procedure.usedCode
Definition

Identifies coded items that were used as part of the procedure.

Control0..*
Terminology BindingProcedureUsed:
TypeCodeableConcept
Comments

For devices actually implanted or removed, use Procedure.device.

Procedure.component
Definition

Identifies medication administrations, other procedures or observations that are related to this procedure.

Control0..*
TypeReference(MedicationAdministration | Procedure | Observation)