Canonical URL: http://fhir.de/StructureDefinition/procedure-de-basis/0.2
| Procedure | 0..* | Procedure | Element IdProcedure An action that is being or was performed on a patient DefinitionAn 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.
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| identifier | Σ | 0..* | Identifier | Element IdProcedure.identifier External Identifiers for this procedure DefinitionThis 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). Need to allow connection to a wider workflow.
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| definition | Σ | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | Element IdProcedure.definition Instantiates protocol or definition DefinitionA protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PlanDefinition | ActivityDefinition | HealthcareService) Constraints
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| basedOn | Σ | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | Element IdProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(CarePlan | ProcedureRequest | ReferralRequest) Constraints
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| partOf | Σ | 0..* | Reference(MedicationAdministration | Procedure, Deutsches Basisprofil (Version 0.2) | Observation, deutsches Basisprofil (Version 0.2)) | Element IdProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, the anesthesia related medicationAdministration is part of the procedure. For an IV medication administration, the procedure to insert the IV port is part of the medication administration. Reference(MedicationAdministration | Procedure, Deutsches Basisprofil (Version 0.2) | Observation, deutsches Basisprofil (Version 0.2)) Constraints
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| status | Σ ?! | 1..1 | codeBinding | Element IdProcedure.status preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally this will be in-progress or completed state. 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.
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| notDone | Σ ?! | 0..1 | boolean | Element IdProcedure.notDone True if procedure was not performed as scheduled DefinitionSet this to true if the record is saying that the procedure was NOT performed. 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. This element is labeled as a modifier because it indicates that a procedure didn't happen.
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| notDoneReason | Σ | 0..1 | CodeableConcept | Element IdProcedure.notDoneReason Reason procedure was not performed DefinitionA code indicating why the procedure was not performed. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. procedure-not-performed-reason (example) Constraints
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| category | Σ | 0..1 | CodeableConcept | Element IdProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| code | Σ | 0..1 | CodeableConcept | Element IdProcedure.code Identification of the procedure Alternate namestype DefinitionThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| coding | Σ | 0..* | Coding | Element IdProcedure.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
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| OPS | Σ | 0..* | CodingBinding | Element IdProcedure.code.coding:OPS Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| system | Σ | 1..1 | uri | Element IdProcedure.code.coding:OPS.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
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| version | Σ | 1..1 | string | Element IdProcedure.code.coding:OPS.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | Element IdProcedure.code.coding:OPS.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
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| display | Σ | 0..1 | string | Element IdProcedure.code.coding:OPS.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
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| userSelected | Σ | 0..1 | boolean | Element IdProcedure.code.coding:OPS.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | Element IdProcedure.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | S Σ | 1..1 | Reference(Group | Patient, deutsches Basisprofil (Version 0.2)) | Element IdProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Group | Patient, deutsches Basisprofil (Version 0.2)) Constraints
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| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Element IdProcedure.context Encounter or episode associated with the procedure Alternate namesencounter DefinitionThe encounter during which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Encounter | EpisodeOfCare) Constraints
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| performed[x] | Σ | 0..1 | Element IdProcedure.performed[x] Date/Period the procedure was performed DefinitionThe 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.
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| performedDateTime | dateTime | Data Type | ||
| performedPeriod | Period | Data Type | ||
| performer | Σ | 0..* | BackboneElement | Element IdProcedure.performer The people who performed the procedure DefinitionLimited to 'real' people rather than equipment.
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| role | Σ | 0..1 | CodeableConcept | Element IdProcedure.performer.role The role the actor was in DefinitionFor example: surgeon, anaethetist, endoscopist. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| actor | Σ | 1..1 | Reference(Organisation, deutsches Basisprofil (Version 0.2) | RelatedPerson | Device | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2)) | Element IdProcedure.performer.actor The reference to the practitioner DefinitionThe practitioner who was involved in the procedure. A reference to Device supports use cases, such as pacemakers. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Organisation, deutsches Basisprofil (Version 0.2) | RelatedPerson | Device | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2)) Constraints
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| onBehalfOf | 0..1 | Reference(Organization) | Element IdProcedure.performer.onBehalfOf Organization the device or practitioner was acting for DefinitionThe organization the device or practitioner was acting on behalf of. Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| location | Σ | 0..1 | Reference(Location) | Element IdProcedure.location Where the procedure happened DefinitionThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Ties a procedure to where the records are likely kept. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| reasonCode | Σ | 0..* | CodeableConcept | Element IdProcedure.reasonCode Coded reason procedure performed DefinitionThe coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| reasonReference | Σ | 0..* | Reference(Observation, deutsches Basisprofil (Version 0.2) | Deutsches Basisprofil einer Condition (Version 0.2)) | Element IdProcedure.reasonReference Condition that is the reason the procedure performed DefinitionThe condition that is the reason why the procedure was performed. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. Reference(Observation, deutsches Basisprofil (Version 0.2) | Deutsches Basisprofil einer Condition (Version 0.2)) Constraints
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| bodySite | Σ | 0..* | CodeableConcept | Element IdProcedure.bodySite Target body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| outcome | Σ | 0..1 | CodeableConcept | Element IdProcedure.outcome The result of procedure DefinitionThe outcome of the procedure - did it resolve reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
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| report | 0..* | Reference(DiagnosticReport) | Element IdProcedure.report Any report resulting from the procedure DefinitionThis could be a histology result, pathology report, surgical report, etc.. 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.
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| complication | 0..* | CodeableConcept | Element IdProcedure.complication Complication following the procedure DefinitionAny 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. If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.
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| complicationDetail | 0..* | Reference(Condition) | Element IdProcedure.complicationDetail A condition that is a result of the procedure DefinitionAny complications that occurred during the procedure, or in the immediate post-performance period. This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| followUp | 0..* | CodeableConcept | Element IdProcedure.followUp Instructions for follow up DefinitionIf 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| note | 0..* | Annotation | Element IdProcedure.note Additional information about the procedure DefinitionAny other notes about the procedure. E.g. the operative notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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| focalDevice | 0..* | BackboneElement | Element IdProcedure.focalDevice Device changed in procedure DefinitionA 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.
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| action | 0..1 | CodeableConceptBinding | Element IdProcedure.focalDevice.action Kind of change to device DefinitionThe kind of change that happened to the device during the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| manipulated | 1..1 | Reference(Device) | Element IdProcedure.focalDevice.manipulated Device that was changed DefinitionThe device that was manipulated (changed) during the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| usedReference | 0..* | Reference(Device | Substance | Medication, deutsches Basisprofil (Version 0.2)) | Element IdProcedure.usedReference Items used during procedure DefinitionIdentifies medications, devices and any other substance used as part of the procedure. Used for tracking contamination, etc. For devices actually implanted or removed, use Procedure.device. Reference(Device | Substance | Medication, deutsches Basisprofil (Version 0.2)) Constraints
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| usedCode | 0..* | CodeableConcept | Element IdProcedure.usedCode Coded items used during the procedure DefinitionIdentifies coded items that were used as part of the procedure. For devices actually implanted or removed, use Procedure.device.
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<Procedure xmlns="http://hl7.org/fhir"> <meta> <profile value="http://fhir.de/StructureDefinition/procedure-de-basis/0.2" /> </meta> <status value="completed" /> <code> <coding> <system value="http://fhir.de/CodeSystem/dimdi/ops" /> <version value="2018" /> <code value="5-320.1" /> <display value="Exzision und Destruktion von erkranktem Gewebe eines Bronchus. Durch Thorakotomie" /> </coding> </code> <subject> <reference value="Patient/12345" /> </subject> <performer> <actor> <reference value="Practitioner/9876" /> </actor> </performer> <reasonReference> <reference value="Condition/246810" /> </reasonReference> </Procedure>
{ "resourceType":"Procedure", "meta":{ "profile": [ "http://fhir.de/StructureDefinition/procedure-de-basis/0.2" ] }, "status":"completed", "code":{ "coding": [ { "system":"http://fhir.de/CodeSystem/dimdi/ops", "version":"2018", "code":"5-320.1", "display":"Exzision und Destruktion von erkranktem Gewebe eines Bronchus. Durch Thorakotomie" } ] }, "subject":{ "reference":"Patient/12345" }, "performer": [ { "actor":{ "reference":"Practitioner/9876" } } ], "reasonReference": [ { "reference":"Condition/246810" } ] }
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