Retrieval of Real World Data for Clinical Research
1.0.0 - trial-use

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## Resource Profile: ProcedureRwd - Detailed Descriptions

Active as of 2023-05-26

Definitions for the ProcedureRwd resource profile.

- Differential Elements Table
- Key Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be found here.

1. Procedure
2. Procedure.status
Must Support | true
3. Procedure.code
Must Support | true
4. Procedure.subject
Type | Reference(IPAPatient|Patient|Group)
Must Support | true
5. Procedure.performed[x]
[x] Note | See Choice of Data Types for further information about how to use [x]
Must Support | true
6. Procedure.outcome
Must Support | true

Guidance on how to interpret the contents of this table can be found here.

1. Procedure
Definition | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.
Control | 0..*
Summary | false
Invariants | Defined on this element dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty()) dom-3: 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-4: 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-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (: text.`div`.exists())
2. Procedure.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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Control | 0..1
Type | uri
Is Modifier | true
Summary | true
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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. Procedure.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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, 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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
4. Procedure.status
Definition | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.
Control | 1..1
Binding | The codes SHALL be taken from EventStatus A code specifying the state of the procedure.
Type | code
Is Modifier | true
Must Support | true
Summary | true
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. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. 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").
Control | 0..1
Binding | For example codes, see ProcedureCodes(SNOMEDCT) A code to identify a specific procedure .
Type | CodeableConcept
Must Support | true
Summary | true
Requirements | 0..1 to account for primarily narrative only resources.
Alternate Names | type
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Procedure.subject
Definition | The person, animal or group on which the procedure was performed.
Control | 1..1
Type | Reference(IPAPatient|Patient|Group)
Must Support | true
Summary | true
Alternate Names | patient
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Procedure.performed[x]
Definition | Estimated or actual date, date-time, period, or age when 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.
Control | 0..1
Type | Choice of: dateTime, Period, string, Age, Range
[x] Note | See Choice of Data Types for further information about how to use [x]
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Comments | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
8. Procedure.outcome
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed?
Control | 0..1
Binding | For example codes, see ProcedureOutcomeCodes(SNOMEDCT) An outcome of a procedure - whether it was resolved or otherwise.
Type | CodeableConcept
Must Support | true
Summary | true
Comments | If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here.

1. Procedure
Definition | An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.
Control | 0..*
Summary | false
2. Procedure.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Control | 0..1
Type | id
Summary | true
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.
3. Procedure.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Control | 0..1
Type | Meta
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. Procedure.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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Control | 0..1
Type | uri
Is Modifier | true
Summary | true
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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. Procedure.language
Definition | The base language in which the resource is written.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages A human language
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Summary | false
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).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. Procedure.text
Definition | A human-readable narrative that contains a summary of the resource and can 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.
Control | 0..1
Type | Narrative
Summary | false
Alternate Names | narrative, html, xhtml, display
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. Procedure.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.
Control | 0..*
Type | Resource
Summary | false
Alternate Names | inline 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
8. Procedure.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, 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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
9. Procedure.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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, 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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. Procedure.identifier
Definition | Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Summary | true
Requirements | Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.
Comments | This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. Procedure.instantiatesCanonical
Definition | The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
Control | 0..*
Type | canonical(PlanDefinition|ActivityDefinition|Measure|OperationDefinition|Questionnaire)
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. Procedure.instantiatesUri
Definition | The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
Control | 0..*
Type | uri
Summary | true
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. Procedure.basedOn
Definition | A reference to a resource that contains details of the request for this procedure.
Control | 0..*
Type | Reference(CarePlan|ServiceRequest)
Summary | true
Alternate Names | fulfills
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. Procedure.partOf
Definition | A larger event of which this particular procedure is a component or step.
Control | 0..*
Type | Reference(Procedure|Observation|MedicationAdministration)
Summary | true
Alternate Names | container
Comments | The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. Procedure.status
Definition | A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.
Control | 1..1
Binding | The codes SHALL be taken from EventStatus A code specifying the state of the procedure
Type | code
Is Modifier | true
Must Support | true
Summary | true
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. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. Procedure.statusReason
Definition | Captures the reason for the current state of the procedure.
Control | 0..1
Binding | For example codes, see ProcedureNotPerformedReason(SNOMED-CT) A code that identifies the reason a procedure was not performed
Type | CodeableConcept
Summary | true
Alternate Names | Suspended Reason, Cancelled Reason
Comments | This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. Procedure.category
Definition | A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").
Control | 0..1
Binding | For example codes, see ProcedureCategoryCodes(SNOMEDCT) A code that classifies a procedure for searching, sorting and display purposes
Type | CodeableConcept
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. 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").
Control | 0..1
Binding | For example codes, see ProcedureCodes(SNOMEDCT) A code to identify a specific procedure
Type | CodeableConcept
Must Support | true
Summary | true
Requirements | 0..1 to account for primarily narrative only resources.
Alternate Names | type
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. Procedure.subject
Definition | The person, animal or group on which the procedure was performed.
Control | 1..1
Type | Reference(IPAPatient)
Must Support | true
Summary | true
Alternate Names | patient
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Procedure.encounter
Definition | The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
Control | 0..1
Type | Reference(Encounter)
Summary | true
Comments | This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. Procedure.performed[x]
Definition | Estimated or actual date, date-time, period, or age when 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.
Control | 0..1
Type | Choice of: dateTime, Period, string, Age, Range
[x] Note | See Choice of Data Types for further information about how to use [x]
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Comments | Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. Procedure.recorder
Definition | Individual who recorded the record and takes responsibility for its content.
Control | 0..1
Type | Reference(Patient|RelatedPerson|Practitioner|PractitionerRole)
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. Procedure.asserter
Definition | Individual who is making the procedure statement.
Control | 0..1
Type | Reference(Patient|RelatedPerson|Practitioner|PractitionerRole)
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. Procedure.performer
Definition | Limited to "real" people rather than equipment.
Control | 0..*
Type | BackboneElement
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. Procedure.performer.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
Summary | false
26. Procedure.performer.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, 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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
27. Procedure.performer.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
28. Procedure.performer.function
Definition | Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.
Control | 0..1
Binding | For example codes, see ProcedurePerformerRoleCodes A code that identifies the role of a performer of the procedure
Type | CodeableConcept
Summary | true
Requirements | Allows disambiguation of the types of involvement of different performers.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. Procedure.performer.actor
Definition | The practitioner who was involved in the procedure.
Control | 1..1
Type | Reference(Practitioner|PractitionerRole|Organization|Patient|RelatedPerson|Device)
Summary | true
Requirements | A reference to Device supports use cases, such as pacemakers.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. Procedure.performer.onBehalfOf
Definition | The organization the device or practitioner was acting on behalf of.
Control | 0..1
Type | Reference(Organization)
Summary | false
Requirements | Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. Procedure.location
Definition | The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
Control | 0..1
Type | Reference(Location)
Summary | true
Requirements | Ties a procedure to where the records are likely kept.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. Procedure.reasonCode
Definition | The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.
Control | 0..*
Binding | For example codes, see ProcedureReasonCodes A code that identifies the reason a procedure is required
Type | CodeableConcept
Summary | true
Comments | Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. Procedure.reasonReference
Definition | The justification of why the procedure was performed.
Control | 0..*
Type | Reference(Condition|Observation|Procedure|DiagnosticReport|DocumentReference)
Summary | true
Comments | It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. Procedure.bodySite
Definition | Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
Control | 0..*
Binding | For example codes, see SNOMEDCTBodyStructures Codes describing anatomical locations. May include laterality
Type | CodeableConcept
Summary | true
Comments | If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. Procedure.outcome
Definition | The outcome of the procedure - did it resolve the reasons for the procedure being performed?
Control | 0..1
Binding | For example codes, see ProcedureOutcomeCodes(SNOMEDCT) An outcome of a procedure - whether it was resolved or otherwise
Type | CodeableConcept
Must Support | true
Summary | true
Comments | If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
36. Procedure.report
Definition | This could be a histology result, pathology report, surgical report, etc.
Control | 0..*
Type | Reference(DiagnosticReport|DocumentReference|Composition)
Summary | false
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. 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.
Control | 0..*
Binding | For example codes, see Condition/Problem/DiagnosisCodes Codes describing complications that resulted from a procedure
Type | CodeableConcept
Summary | false
Comments | If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
38. Procedure.complicationDetail
Definition | Any complications that occurred during the procedure, or in the immediate post-performance period.
Control | 0..*
Type | Reference(Condition)
Summary | false
Requirements | This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
39. Procedure.followUp
Definition | If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.
Control | 0..*
Binding | For example codes, see ProcedureFollowUpCodes(SNOMEDCT) Specific follow up required for a procedure e.g. removal of sutures
Type | CodeableConcept
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. Procedure.note
Definition | Any other notes and comments about the procedure.
Control | 0..*
Type | Annotation
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. 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.
Control | 0..*
Type | BackboneElement
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. Procedure.focalDevice.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
Summary | false
43. Procedure.focalDevice.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, 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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
44. Procedure.focalDevice.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
45. Procedure.focalDevice.action
Definition | The kind of change that happened to the device during the procedure.
Control | 0..1
Binding | The codes SHOULD be taken from ProcedureDeviceActionCodes A kind of change that happened to the device during the procedure
Type | CodeableConcept
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
46. Procedure.focalDevice.manipulated
Definition | The device that was manipulated (changed) during the procedure.
Control | 1..1
Type | Reference(Device)
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
47. Procedure.usedReference
Definition | Identifies medications, devices and any other substance used as part of the procedure.
Control | 0..*
Type | Reference(Device|Medication|Substance)
Summary | false
Requirements | Used for tracking contamination, etc.
Comments | For devices actually implanted or removed, use Procedure.device.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
48. Procedure.usedCode
Definition | Identifies coded items that were used as part of the procedure.
Control | 0..*
Binding | For example codes, see FHIRDeviceTypes Codes describing items used during a procedure
Type | CodeableConcept
Summary | false
Comments | For devices actually implanted or removed, use Procedure.device.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))