---
type: "resource-definitions"
title: "Procedure Definitions"
resource: "Procedure"
---

# Procedure Definitions

<a id="Procedure"></a>

## 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


<a id="Procedure.identifier"></a>

## 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](resource.html#identifiers)).  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](/Identifier)

**Summary:** true

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


<a id="Procedure.basedOn"></a>

## 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](/CarePlan), [ServiceRequest](/ServiceRequest), [MedicationRequest](/MedicationRequest))

**Summary:** true

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


<a id="Procedure.partOf"></a>

## 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](/Procedure), [Observation](/Observation), [MedicationAdministration](/MedicationAdministration))

**Summary:** true

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


<a id="Procedure.status"></a>

## Procedure.status
preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown

**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](/code)

**Binding:** required:[event-status](/valueset-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


<a id="Procedure.statusReason"></a>

## 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](/CodeableConcept)

**Binding:** example:[procedure-not-performed-reason](/valueset-procedure-not-performed-reason)

**Summary:** true

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


<a id="Procedure.category"></a>

## 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](/CodeableConcept)

**Binding:** example:[procedure-category](/valueset-procedure-category)

**Summary:** true

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


<a id="Procedure.code"></a>

## 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](/CodeableConcept)

**Binding:** example:[procedure-code](/valueset-procedure-code)

**Summary:** true

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


<a id="Procedure.subject"></a>

## 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](/Patient), [Group](/Group), [Device](/Device), [Practitioner](/Practitioner), [Organization](/Organization), [Location](/Location))

**Summary:** true

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


<a id="Procedure.focus"></a>

## 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](/Patient), [Group](/Group), [RelatedPerson](/RelatedPerson), [Practitioner](/Practitioner), [Organization](/Organization), [CareTeam](/CareTeam), [PractitionerRole](/PractitionerRole), [Specimen](/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


<a id="Procedure.encounter"></a>

## 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](/Encounter))

**Summary:** true

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


<a id="Procedure.occurrence[x]"></a>

## 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](/dateTime), [Period](/Period), [string](/string), [Age](/Age), [Range](/Range), [Timing](/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


<a id="Procedure.recorded"></a>

## 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](/dateTime)

**Summary:** true

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


<a id="Procedure.recorder"></a>

## 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](/Patient), [RelatedPerson](/RelatedPerson), [Practitioner](/Practitioner), [PractitionerRole](/PractitionerRole))

**Summary:** true

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


<a id="Procedure.reported[x]"></a>

## 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](/boolean), Reference([Patient](/Patient), [RelatedPerson](/RelatedPerson), [Practitioner](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/Organization))

**Summary:** true

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


<a id="Procedure.performer"></a>

## 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](/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]


<a id="Procedure.performer.function"></a>

## 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](/CodeableConcept)

**Binding:** example:[participant-role](/valueset-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


<a id="Procedure.performer.actor"></a>

## 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](/Practitioner), [PractitionerRole](/PractitionerRole), [Organization](/Organization), [Patient](/Patient), [RelatedPerson](/RelatedPerson), [Device](/Device), [CareTeam](/CareTeam), [HealthcareService](/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


<a id="Procedure.performer.onBehalfOf"></a>

## 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](/Organization))

**Mappings:** rim=.scoper


<a id="Procedure.performer.period"></a>

## Procedure.performer.period
When the performer performed the procedure

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

**Cardinality:** 0..1

**Type:** [Period](/Period)


<a id="Procedure.location"></a>

## 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](/Location))

**Summary:** true

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


<a id="Procedure.reason"></a>

## 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](/CodeableReference)

**Binding:** example:[procedure-reason](/valueset-procedure-reason)

**Summary:** true

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


<a id="Procedure.bodySite"></a>

## 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](/CodeableConcept)

**Binding:** example:[body-site](/valueset-body-site)

**Summary:** true

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


<a id="Procedure.bodyStructure"></a>

## 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](/BodyStructure))

**Mappings:** rim=targetSiteCode


<a id="Procedure.outcome"></a>

## 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](/CodeableReference)

**Binding:** example:[procedure-outcome](/valueset-procedure-outcome)

**Summary:** true

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


<a id="Procedure.report"></a>

## 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](/DiagnosticReport), [DocumentReference](/DocumentReference), [Composition](/Composition), [Bundle](/Bundle))

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


<a id="Procedure.complication"></a>

## 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](/CodeableReference)

**Binding:** example:[condition-code](/valueset-condition-code)

**Summary:** true

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


<a id="Procedure.followUp"></a>

## 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](/CodeableReference)

**Binding:** example:[procedure-followup](/valueset-procedure-followup)

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


<a id="Procedure.note"></a>

## Procedure.note
Additional information about the procedure

**Definition:** Any other notes and comments about the procedure.

**Cardinality:** 0..*

**Type:** [Annotation](/Annotation)

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


<a id="Procedure.focalDevice"></a>

## 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](/BackboneElement)

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


<a id="Procedure.focalDevice.action"></a>

## 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](/CodeableConcept)

**Binding:** preferred:[device-action](/valueset-device-action)

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


<a id="Procedure.focalDevice.manipulated"></a>

## Procedure.focalDevice.manipulated
Device that was changed

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

**Cardinality:** 1..1

**Type:** Reference([Device](/Device))

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


<a id="Procedure.used"></a>

## 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](/CodeableReference)

**Binding:** example:[device-type](/valueset-device-type)

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


<a id="Procedure.supportingInfo"></a>

## 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](/Resource))

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