Procedure

Key: = Must support, = QICore-defined extension, = Is-Modifier

Field	Card.	Type and Description
approachBodySite	`0..*`	`List<Extension>` An Extension
basedOn	`0..*`	`List<Reference>` A reference to a resource that contains details of the request for this procedure.
bodySite	`0..*`	`List<Concept>` Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Binding: SNOMED CT Body Structures (Example)
category	`0..1`	`Concept` A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Binding: Procedure Category Codes (SNOMED CT) (Example)
code	`1..1`	`Concept` The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). Binding: value set (Preferred)
complication	`0..*`	`List<Concept>` 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. Binding: Condition/Problem/Diagnosis Codes (Example)
complicationDetail	`0..*`	`List<Reference>` Any complications that occurred during the procedure, or in the immediate post-performance period.
context	`0..1`	`Reference` The encounter during which the procedure was performed.
definition	`0..*`	`List<Reference>` A protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure.
focalDevice	`0..*`	`List<FocalDevice>` 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.
followUp	`0..*`	`List<Concept>` 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. Binding: Procedure Follow up Codes (SNOMED CT) (Example)
identifier	`0..*`	`List<Identifier>` 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).
incisionDateTime	`0..1`	`Extension` The time of the first incision.
location	`0..1`	`Reference` The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
notDone	`0..1`	`Boolean` Set this to true if the record is saying that the procedure was NOT performed.
notDoneReason	`0..1`	`Concept` A code indicating why the procedure was not performed. Binding: Procedure Not Performed Reason (SNOMED-CT) (Example)
note	`0..*`	`List<Annotation>` Any other notes about the procedure. E.g. the operative notes.
outcome	`0..1`	`Concept` The outcome of the procedure - did it resolve reasons for the procedure being performed? Binding: Procedure Outcome Codes (SNOMED CT) (Example)
partOf	`0..*`	`List<Reference>` A larger event of which this particular procedure is a component or step.
performed[x]	`1..1`	`Interval<DateTime \| Interval<DateTime>` 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.
performer	`0..*`	`List<Performer>` Limited to 'real' people rather than equipment.
reasonCode	`0..*`	`List<Concept>` The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text. Binding: Procedure Reason Codes (Example)
reasonReference	`0..*`	`List<Reference>` The condition that is the reason why the procedure was performed.
report	`0..*`	`List<Reference>` This could be a histology result, pathology report, surgical report, etc..
status	`1..1`	`String` A code specifying the state of the procedure. Generally this will be in-progress or completed state. Binding: EventStatus (Required)
subject	`1..1`	`Reference` The person, animal or group on which the procedure was performed.
usedCode	`0..*`	`List<Concept>` Identifies coded items that were used as part of the procedure. Binding: FHIR Device Types (Example)
usedReference	`0..*`	`List<Reference>` Identifies medications, devices and any other substance used as part of the procedure.

Key: = Must support, = QICore-defined extension, = Is-Modifier