DRAFT Implementation Guide

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Resource Profile: Procedure

DRAFT Extension of UKCore-Procedure

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
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This structure is derived from UKCoreProcedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	UKCoreProcedure	An action that is being or was performed on a patient
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	UKCoreProcedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated 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 dom-6: A resource should have narrative for robust management dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣ	1..1	code	A code specifying the state of the procedure. Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
code	SΣ	0..1	CodeableConcept	A code identifying the procedure performed. Binding: UK Core Procedure Code (preferred): A code from the SNOMED Clinical Terminology UK. ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(Patient | Group)	Who the procedure was performed on. ele-1: All FHIR elements must have a @value or children ref-1: SHALL have a contained resource if a local reference is provided
performed[x]	SΣ	0..1		When the procedure was performed. ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	preferred	UKCoreProcedureCode https://fhir.hl7.org.uk/ValueSet/UKCore-ProcedureCode

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	UKCoreProcedure	An action that is being or was performed on a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	ΣC	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure ref-1: SHALL have a contained resource if a local reference is provided
partOf	ΣC	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event ref-1: SHALL have a contained resource if a local reference is provided
status	?!SΣ	1..1	code	A code specifying the state of the procedure. Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SΣ	0..1	CodeableConcept	A code identifying the procedure performed. Binding: UK Core Procedure Code (preferred): A code from the SNOMED Clinical Terminology UK.
subject	SΣC	1..1	Reference(Patient | Group)	Who the procedure was performed on. ref-1: SHALL have a contained resource if a local reference is provided
encounter	ΣC	0..1	Reference(Encounter)	Encounter created as part of ref-1: SHALL have a contained resource if a local reference is provided
performed[x]	SΣ	0..1		When the procedure was performed.
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	ΣC	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure ref-1: SHALL have a contained resource if a local reference is provided
asserter	ΣC	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure ref-1: SHALL have a contained resource if a local reference is provided
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner ref-1: SHALL have a contained resource if a local reference is provided
onBehalfOf	C	0..1	Reference(Organization)	Organization the device or practitioner was acting for ref-1: SHALL have a contained resource if a local reference is provided
location	ΣC	0..1	Reference(Location)	Where the procedure happened ref-1: SHALL have a contained resource if a local reference is provided
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	ΣC	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed ref-1: SHALL have a contained resource if a local reference is provided
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (preferred): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report	C	0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure ref-1: SHALL have a contained resource if a local reference is provided
complication		0..*	CodeableConcept	Complication following the procedure Binding: UK Core Condition Code (preferred): A code from the SNOMED Clinical Terminology UK with the expression (<404684003 |Clinical finding| OR <413350009 |Finding with explicit context| OR <272379006 |Event|).
complicationDetail	C	0..*	Reference(Condition)	A condition that is a result of the procedure ref-1: SHALL have a contained resource if a local reference is provided
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated	C	1..1	Reference(Device)	Device that was changed ref-1: SHALL have a contained resource if a local reference is provided
usedReference	C	0..*	Reference(Device | Medication | Substance)	Items used during procedure ref-1: SHALL have a contained resource if a local reference is provided
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	preferred	UKCoreProcedureCode https://fhir.hl7.org.uk/ValueSet/UKCore-ProcedureCode
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	preferred	UKCoreConditionCode https://fhir.hl7.org.uk/ValueSet/UKCore-ConditionCode
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

This structure is derived from UKCoreProcedure

Summary

Differential View

This structure is derived from UKCoreProcedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	UKCoreProcedure	An action that is being or was performed on a patient
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	UKCoreProcedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated 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 dom-6: A resource should have narrative for robust management dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣ	1..1	code	A code specifying the state of the procedure. Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
code	SΣ	0..1	CodeableConcept	A code identifying the procedure performed. Binding: UK Core Procedure Code (preferred): A code from the SNOMED Clinical Terminology UK. ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(Patient | Group)	Who the procedure was performed on. ele-1: All FHIR elements must have a @value or children ref-1: SHALL have a contained resource if a local reference is provided
performed[x]	SΣ	0..1		When the procedure was performed. ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	preferred	UKCoreProcedureCode https://fhir.hl7.org.uk/ValueSet/UKCore-ProcedureCode

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	UKCoreProcedure	An action that is being or was performed on a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	ΣC	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure ref-1: SHALL have a contained resource if a local reference is provided
partOf	ΣC	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event ref-1: SHALL have a contained resource if a local reference is provided
status	?!SΣ	1..1	code	A code specifying the state of the procedure. Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SΣ	0..1	CodeableConcept	A code identifying the procedure performed. Binding: UK Core Procedure Code (preferred): A code from the SNOMED Clinical Terminology UK.
subject	SΣC	1..1	Reference(Patient | Group)	Who the procedure was performed on. ref-1: SHALL have a contained resource if a local reference is provided
encounter	ΣC	0..1	Reference(Encounter)	Encounter created as part of ref-1: SHALL have a contained resource if a local reference is provided
performed[x]	SΣ	0..1		When the procedure was performed.
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	ΣC	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure ref-1: SHALL have a contained resource if a local reference is provided
asserter	ΣC	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure ref-1: SHALL have a contained resource if a local reference is provided
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	ΣC	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner ref-1: SHALL have a contained resource if a local reference is provided
onBehalfOf	C	0..1	Reference(Organization)	Organization the device or practitioner was acting for ref-1: SHALL have a contained resource if a local reference is provided
location	ΣC	0..1	Reference(Location)	Where the procedure happened ref-1: SHALL have a contained resource if a local reference is provided
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	ΣC	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed ref-1: SHALL have a contained resource if a local reference is provided
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (preferred): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report	C	0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure ref-1: SHALL have a contained resource if a local reference is provided
complication		0..*	CodeableConcept	Complication following the procedure Binding: UK Core Condition Code (preferred): A code from the SNOMED Clinical Terminology UK with the expression (<404684003 |Clinical finding| OR <413350009 |Finding with explicit context| OR <272379006 |Event|).
complicationDetail	C	0..*	Reference(Condition)	A condition that is a result of the procedure ref-1: SHALL have a contained resource if a local reference is provided
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated	C	1..1	Reference(Device)	Device that was changed ref-1: SHALL have a contained resource if a local reference is provided
usedReference	C	0..*	Reference(Device | Medication | Substance)	Items used during procedure ref-1: SHALL have a contained resource if a local reference is provided
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	preferred	UKCoreProcedureCode https://fhir.hl7.org.uk/ValueSet/UKCore-ProcedureCode
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	preferred	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	preferred	UKCoreConditionCode https://fhir.hl7.org.uk/ValueSet/UKCore-ConditionCode
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

This structure is derived from UKCoreProcedure

Summary

Other representations of profile: CSV, Excel, Schematron