type: resource-definitionsresource: Procedure

Procedure Definitions

Procedure

An action that is being or was performed on an individual or entity

Definition: An action that is or was performed on or for a patient, practitioner, device, organization, or location. For example, this can be a physical intervention on a patient like an operation, or less invasive like long term services, counseling, or hypnotherapy. This can be a quality or safety inspection for a location, organization, or device. This can be an accreditation procedure on a practitioner for licensing.

Cardinality: 0..*

Constraints: con-4 | error | bodyStructure SHALL only be present if Procedure.bodySite is not present | bodySite.exists() implies bodyStructure.empty()

Mappings: workflow=Event; rim=Procedure[moodCode=EVN]; w5=clinical.general

Procedure.identifier

External Identifiers for this procedure

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.

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.

Requirements: Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: workflow=Event.identifier; w5=FiveWs.identifier; v2=PR1-19; rim=.id

Procedure.basedOn

A request for this procedure

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

Aliases: fulfills

Cardinality: 0..*

Type: Reference(CarePlan, ServiceRequest, MedicationRequest)

Summary: true

Mappings: workflow=Event.basedOn; rim=.outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code

Procedure.partOf

Part of referenced event

Definition: A larger event of which this particular procedure is a component or step.

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).

Aliases: container

Cardinality: 0..*

Type: Reference(Procedure, Observation, MedicationAdministration)

Summary: true

Mappings: workflow=Event.partOf; v2=PR1-25; rim=.inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]

Procedure.status

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

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.

Cardinality: 1..1

Type: code

Binding: required:event-status

Summary: true

Is Modifier: true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status; rim=statusCode

Procedure.statusReason

Reason for current status

Definition: Captures the reason for the current state of the procedure.

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.

Aliases: Suspended Reason, Cancelled Reason

Cardinality: 0..1

Type: CodeableConcept

Binding: example:procedure-not-performed-reason

Summary: true

Mappings: workflow=Event.statusReason; rim=.reason.Observation.value

Procedure.category

Classification of the procedure

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

Cardinality: 0..*

Type: CodeableConcept

Binding: example:procedure-category

Summary: true

Mappings: w5=FiveWs.class; v2=PR1-6; rim=.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code

Procedure.code

Identification of the procedure

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

Requirements: 0..1 to account for primarily narrative only resources.

Aliases: type

Cardinality: 0..1

Type: CodeableConcept

Binding: example:procedure-code

Summary: true

Mappings: workflow=Event.code; w5=FiveWs.what[x]; v2=PR1-3; rim=.code

Procedure.subject

Individual or entity the procedure was performed on

Definition: On whom or on what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure.

Aliases: patient

Cardinality: 1..1

Type: Reference(Patient, Group, Device, Practitioner, Organization, Location)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject; v2=PID-3; rim=.participation[typeCode=SBJ].role

Procedure.focus

Who is the target of the procedure when it is not the subject of record only

Definition: Who is the target of the procedure when it is not the subject of record only. If focus is not present, then subject is the focus. If focus is present and the subject is one of the targets of the procedure, include subject as a focus as well. If focus is present and the subject is not included in focus, it implies that the procedure was only targeted on the focus. For example, when a caregiver is given education for a patient, the caregiver would be the focus and the procedure record is associated with the subject (e.g. patient). For example, use focus when recording the target of the education, training, or counseling is the parent or relative of a patient.

Cardinality: 0..1

Type: Reference(Patient, Group, RelatedPerson, Practitioner, Organization, CareTeam, PractitionerRole, Specimen)

Summary: true

Is Modifier: true (Reason: This element is labeled as a modifier because it changes who is the target of the procedure.)

Mappings: w5=FiveWs.subject

Procedure.encounter

The Encounter during which this Procedure was created

Definition: The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

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.

Cardinality: 0..1

Type: Reference(Encounter)

Summary: true

Mappings: workflow=Event.encounter; w5=FiveWs.context; v2=PV1-19; rim=.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]

Procedure.occurrence[x]

When the procedure occurred or is occurring

Definition: Estimated or actual date, date-time, period, or age when the procedure did occur or is occurring. 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.

Comments: This indicates when the procedure actually occurred or is occurring, not when it was asked/requested/ordered to occur. For the latter, look at the occurence element of the Request this Procedure is "basedOn". The status code allows differentiation of whether the timing reflects a historic event or an ongoing event. Ongoing events should not include an upper bound in the Period or Timing.bounds.

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.

Cardinality: 0..1

Type: dateTime, Period, string, Age, Range, Timing

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.done[x]; v2=PR1-5 - occurrencePeriod.end can be inferred when both PR1-5 (Procedure Date/Time) and PR1-7 (Procedure Minutes) are populated; rim=.effectiveTime

Procedure.recorded

When the procedure was first captured in the subject's record

Definition: The date the occurrence of the procedure was first captured in the record regardless of Procedure.status (potentially after the occurrence of the event).

Cardinality: 0..1

Type: dateTime

Summary: true

Mappings: workflow=Event.recorded; w5=FiveWs.recorded; rim=.participation[typeCode=AUT].time

Procedure.recorder

Who recorded the procedure

Definition: Individual who recorded the record and takes responsibility for its content.

Comments: The recorder takes responsibility for the recorded content. The source from where they got the information can be captured using reportedReference. If you want to capture the scribe, that's typically handled with Provenance.

Cardinality: 0..1

Type: Reference(Patient, RelatedPerson, Practitioner, PractitionerRole)

Summary: true

Mappings: w5=FiveWs.author; rim=.participation[typeCode=AUT].role

Procedure.reported[x]

Reported rather than primary record

Definition: Indicates if this record was captured as a secondary 'reported' record rather than as an original primary source-of-truth record. It may also indicate the source of the report.

Requirements: Reported data may have different rules on editing and may be visually distinguished from primary data.

Aliases: informer

Cardinality: 0..1

Type: boolean, Reference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization)

Summary: true

Mappings: workflow=Event.reported[x]; w5=FiveWs.source; rim=.participation[typeCode=RPT].role

Procedure.performer

Who performed the procedure and what they did

Definition: Indicates who or what performed the procedure and how they were involved.

Cardinality: 0..*

Type: BackboneElement

Summary: true

Constraints: prc-1 | error | Procedure.performer.onBehalfOf can only be populated when performer.actor isn't Practitioner or PractitionerRole | onBehalfOf.exists() and actor.resolve().exists() implies actor.resolve().where($this is Practitioner or $this is PractitionerRole).empty()

Mappings: workflow=Event.performer; rim=.participation[typeCode=PRF]

Procedure.performer.function

Type of performance

Definition: Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Requirements: Allows disambiguation of the types of involvement of different performers.

Cardinality: 0..1

Type: CodeableConcept

Binding: example:participant-role

Summary: true

Mappings: workflow=Event.performer.function; v2=Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25; rim=.functionCode

Procedure.performer.actor

Who performed the procedure

Definition: Indicates who or what performed the procedure.

Requirements: A reference to Device supports use cases, such as pacemakers.

Conditions: prc-1

Cardinality: 1..1

Type: Reference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson, Device, CareTeam, HealthcareService)

Summary: true

Mappings: workflow=Event.performer.actor; w5=FiveWs.actor; v2=PR1-8 (Anesthesiologist), PR1-11 (Surgeon), PR1-12 (Procedure Practitioner) --> Procedure.performer.actor where Procedure.performer.function is also populated; rim=.role

Procedure.performer.onBehalfOf

Organization the device or practitioner was acting for

Definition: The Organization the Patient, RelatedPerson, Device, CareTeam, and HealthcareService was acting on behalf of.

Comments: Organization, Patient, RelatedPerson, Device, CareTeam, and HealthcareService can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

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.

Conditions: prc-1

Cardinality: 0..1

Type: Reference(Organization)

Mappings: rim=.scoper

Procedure.performer.period

When the performer performed the procedure

Definition: Time period during which the performer performed the procedure.

Cardinality: 0..1

Type: Period

Procedure.location

Where the procedure happened

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

Cardinality: 0..1

Type: Reference(Location)

Summary: true

Mappings: w5=FiveWs.where[x]; v2=PR1-23; rim=.participation[typeCode=LOC].role[classCode=SDLOC]

Procedure.reason

The justification that the procedure was performed

Definition: The coded reason or reference why the procedure was performed. This may be a coded entity of some type, be present as text, or be a reference to one of several resources that justify the procedure.

Comments: Use Procedure.reason.concept when a code sufficiently describes the reason. Use Procedure.reason.reference when referencing a resource, which allows more information to be conveyed, such as onset date. For a single Procedure.reason, if both Procedure.reason.concept and Procedure.reason.reference are present, they are expected to be consistent with each other.

Cardinality: 0..*

Type: CodeableReference

Binding: example:procedure-reason

Summary: true

Mappings: workflow=Event.reason; w5=FiveWs.why[x]; v2=PR1-15; rim=.reasonCode

Procedure.bodySite

Target body sites

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

Conditions: con-4

Cardinality: 0..*

Type: CodeableConcept

Binding: example:body-site

Summary: true

Mappings: v2=OBX-20; rim=.targetSiteCode

Procedure.bodyStructure

Target body structure

Definition: Indicates the body structure on the subject's body where the procedure was performed.

Comments: Should be consistent with Procedure.code. Cannot be used if Procedure.bodySite is used.

Cardinality: 0..1

Type: Reference(BodyStructure)

Mappings: rim=targetSiteCode

Procedure.outcome

The result of procedure

Definition: The short term outcome of the procedure assessed during the procedure, at the conclusion of the procedure, during the immediate post-performance period, or at discharge. The outcome is usually expected to be within the encounter during which the procedure was performed.

Comments: If outcome contains narrative text only, it can be captured using the CodeableConcept.text. Procedure.outcome are short term outcomes because long term outcomes are typically documented as Observations. For example, a cardiac stent procedure may have two Procedure.outcomes of successful placement of stent and successful reestablishment of blood flow, but the long term outcome of no further cardiac events would not be documented as a Procedure.outcome and instead documented as an Observation. In the ICU where patient is intubated and attached to a ventilator, the ventilator parameter settings can include respiratory rate, tidal volume, FiO2, and PEEP. The Procedure.code = ventilator parameter adjustment. The Procedure.outcome is 0..* Reference(Observation) where each Observation instance supports documenting respiratory rate, tidal volume, FiO2, and PEEP.

Cardinality: 0..*

Type: CodeableReference

Binding: example:procedure-outcome

Summary: true

Mappings: rim=.outboundRelationship[typeCode=OUT].target.text

Procedure.report

Any report resulting from the procedure

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

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.

Cardinality: 0..*

Type: Reference(DiagnosticReport, DocumentReference, Composition, Bundle)

Mappings: rim=.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]

Procedure.complication

Complication following the procedure

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.

Comments: If complications are only expressed by the narrative text, they can be captured using the CodeableReference.concept.text.

Cardinality: 0..*

Type: CodeableReference

Binding: example:condition-code

Summary: true

Mappings: rim=.outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value

Procedure.followUp

Instructions for follow up

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. CarePlan can reference the Procedure via CarePlan.addresses.

Cardinality: 0..*

Type: CodeableReference

Binding: example:procedure-followup

Mappings: rim=.outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code

Procedure.note

Additional information about the procedure

Definition: Any other notes and comments about the procedure.

Cardinality: 0..*

Type: Annotation

Mappings: workflow=Event.note; v2=NTE; rim=.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value

Procedure.focalDevice

Manipulated, implanted, or removed device

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.

Cardinality: 0..*

Type: BackboneElement

Mappings: rim=.participation[typeCode=DEV].role[classCode=MANU]

Procedure.focalDevice.action

Kind of change to device

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

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:device-action

Mappings: rim=.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes

Procedure.focalDevice.manipulated

Device that was changed

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

Cardinality: 1..1

Type: Reference(Device)

Mappings: rim=.participation[typeCode=DEV].role[classCode=SDLOC]

Procedure.used

Items used during procedure

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

Comments: For devices actually implanted or removed, use Procedure.focalDevice.manipulated.

Requirements: Used for tracking contamination, etc.

Cardinality: 0..*

Type: CodeableReference

Binding: example:device-type

Mappings: rim=participation[typeCode=Dev].role[classCode=MANU]

Procedure.supportingInfo

Extra information relevant to the procedure

Definition: Other resources from the patient record that may be relevant to the procedure. The information from these resources was either used to create the instance or is provided to help with its interpretation. This extension should not be used if more specific inline elements or extensions are available.

Cardinality: 0..*

Type: Reference(Resource)

Mappings: rim=.outboundRelationship[typeCode=PERT].target