Guia de Implementação do AnHealth - Local Development build (v0.2.0). See the Directory of published versions
Resource Profile: Procedure
| Official URL: https://ancode.app/fhir/StructureDefinition/Procedure | Version: 0.2.0 | |||
| Draft as of 2021-11-30 | Computable Name: 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.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
  Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
 performedQuantity | 1..1 | Quantity | Extension URL: https://ancode.app/fhir/StructureDefinition/PerformedQuantity | |
 basedOn | 1..1 | Reference(ServiceRequest) | A request for this procedure | |
 category | 1..1 | CodeableConcept | Classification of the procedure Binding: BRTecnicaUtilizada (required) | |
| code | 1..1 | CodeableConcept | Identification of the procedure | |
| subject | 1..1 | Reference(Patient) | Who the procedure was performed on | |
| encounter | 1..1 | Reference(Encounter) | Encounter created as part of | |
  performed[x] | 1..1 | Period | When the procedure was performed | |
 start | 1..1 | dateTime | Starting time with inclusive boundary | |
 end | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | |
| recorder | 1..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |
| performer | 1..* | BackboneElement | The people who performed the procedure | |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cboHealthcare | 1..1 | CodeableConcept | Extension URL: https://ancode.app/fhir/StructureDefinition/CBOHealthcare Binding: CBOHealthcare (required) | |
| function | 1..1 | CodeableConcept | Type of performance Binding: BRGrauParticipacao (required) | |
| actor | 1..1 | Reference(Practitioner | PractitionerRole | Device) | The reference to the practitioner | |
| onBehalfOf | 1..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | 1..1 | Reference(Location) | Where the procedure happened | |
| reasonCode | 0..* | CodeableConcept | Coded reason procedure performed Binding: BRCID10 (required) | |
| bodySite | 0..1 | CodeableConcept | Target body sites Binding: BRViaAcesso (required) | |
| Documentation for this format | ||||
Terminology Bindings (Differential)
| Path | Conformance | ValueSet |
| Procedure.category | required | BRTecnicaUtilizada |
| Procedure.performer.function | required | BRGrauParticipacao |
| Procedure.reasonCode | required | BRCID10 (a valid code from Classificação Internacional de Doenças - Décima Revisão - CID-10) |
| Procedure.bodySite | required | BRViaAcesso |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| performedQuantity | 1..1 | Quantity | Extension URL: https://ancode.app/fhir/StructureDefinition/PerformedQuantity | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn | Σ | 1..1 | Reference(ServiceRequest) | A request for this procedure |
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
| category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: BRTecnicaUtilizada (required) |
| code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject | Σ | 1..1 | Reference(Patient) | Who the procedure was performed on |
| encounter | Σ | 1..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | Σ | 1..1 | Period | When the procedure was performed |
| start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary |
| end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing |
| recorder | Σ | 1..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure |
| performer | Σ | 1..* | BackboneElement | The people who performed the procedure |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cboHealthcare | 1..1 | CodeableConcept | Extension URL: https://ancode.app/fhir/StructureDefinition/CBOHealthcare Binding: CBOHealthcare (required) | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | Σ | 1..1 | CodeableConcept | Type of performance Binding: BRGrauParticipacao (required) |
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Device) | The reference to the practitioner |
| onBehalfOf | 1..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 1..1 | Reference(Location) | Where the procedure happened |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: BRCID10 (required) |
| bodySite | Σ | 0..1 | CodeableConcept | Target body sites Binding: BRViaAcesso (required) |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet |
| Procedure.status | required | EventStatus |
| Procedure.category | required | BRTecnicaUtilizada |
| Procedure.code | example | ProcedureCodes(SNOMEDCT) |
| Procedure.performer.function | required | BRGrauParticipacao |
| Procedure.reasonCode | required | BRCID10 (a valid code from Classificação Internacional de Doenças - Décima Revisão - CID-10) |
| Procedure.bodySite | required | BRViaAcesso |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | 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.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | 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 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | 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): IETF language tag
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| performedQuantity | 1..1 | Quantity | Extension URL: https://ancode.app/fhir/StructureDefinition/PerformedQuantity | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| 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 | Σ | 1..1 | Reference(ServiceRequest) | A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown 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 | 1..1 | CodeableConcept | Classification of the procedure Binding: BRTecnicaUtilizada (required) | ||||
| code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject | Σ | 1..1 | Reference(Patient) | Who the procedure was performed on | ||||
| encounter | Σ | 1..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | Σ | 1..1 | Period | When the procedure was performed | ||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
| end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| recorder | Σ | 1..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 1..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| cboHealthcare | 1..1 | CodeableConcept | Extension URL: https://ancode.app/fhir/StructureDefinition/CBOHealthcare Binding: CBOHealthcare (required) | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 1..1 | CodeableConcept | Type of performance Binding: BRGrauParticipacao (required) | ||||
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Device) | The reference to the practitioner | ||||
| onBehalfOf | 1..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 1..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: BRCID10 (required) | ||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite | Σ | 0..1 | CodeableConcept | Target body sites Binding: BRViaAcesso (required) | ||||
| 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 | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| 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 | 0..* | Extension | Additional content defined by implementations | |||||
| 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 | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| 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 | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | EventStatus | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
| Procedure.category | required | BRTecnicaUtilizada | ||||
| Procedure.code | example | ProcedureCodes(SNOMEDCT) | ||||
| Procedure.performer.function | required | BRGrauParticipacao | ||||
| Procedure.reasonCode | required | BRCID10 (a valid code from Classificação Internacional de Doenças - Décima Revisão - CID-10) | ||||
| Procedure.bodySite | required | BRViaAcesso | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-r4b | warning | Procedure.contained | Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic) | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Procedure
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| performedQuantity | 1..1 | Quantity | Extension URL: https://ancode.app/fhir/StructureDefinition/PerformedQuantity | |
| basedOn | 1..1 | Reference(ServiceRequest) | A request for this procedure | |
| category | 1..1 | CodeableConcept | Classification of the procedure Binding: BRTecnicaUtilizada (required) | |
| code | 1..1 | CodeableConcept | Identification of the procedure | |
| subject | 1..1 | Reference(Patient) | Who the procedure was performed on | |
| encounter | 1..1 | Reference(Encounter) | Encounter created as part of | |
| performed[x] | 1..1 | Period | When the procedure was performed | |
| start | 1..1 | dateTime | Starting time with inclusive boundary | |
| end | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | |
| recorder | 1..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |
| performer | 1..* | BackboneElement | The people who performed the procedure | |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cboHealthcare | 1..1 | CodeableConcept | Extension URL: https://ancode.app/fhir/StructureDefinition/CBOHealthcare Binding: CBOHealthcare (required) | |
| function | 1..1 | CodeableConcept | Type of performance Binding: BRGrauParticipacao (required) | |
| actor | 1..1 | Reference(Practitioner | PractitionerRole | Device) | The reference to the practitioner | |
| onBehalfOf | 1..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | 1..1 | Reference(Location) | Where the procedure happened | |
| reasonCode | 0..* | CodeableConcept | Coded reason procedure performed Binding: BRCID10 (required) | |
| bodySite | 0..1 | CodeableConcept | Target body sites Binding: BRViaAcesso (required) | |
| Documentation for this format | ||||
Terminology Bindings (Differential)
| Path | Conformance | ValueSet |
| Procedure.category | required | BRTecnicaUtilizada |
| Procedure.performer.function | required | BRGrauParticipacao |
| Procedure.reasonCode | required | BRCID10 (a valid code from Classificação Internacional de Doenças - Décima Revisão - CID-10) |
| Procedure.bodySite | required | BRViaAcesso |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| performedQuantity | 1..1 | Quantity | Extension URL: https://ancode.app/fhir/StructureDefinition/PerformedQuantity | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn | Σ | 1..1 | Reference(ServiceRequest) | A request for this procedure |
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
| category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: BRTecnicaUtilizada (required) |
| code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject | Σ | 1..1 | Reference(Patient) | Who the procedure was performed on |
| encounter | Σ | 1..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | Σ | 1..1 | Period | When the procedure was performed |
| start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary |
| end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing |
| recorder | Σ | 1..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure |
| performer | Σ | 1..* | BackboneElement | The people who performed the procedure |
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| cboHealthcare | 1..1 | CodeableConcept | Extension URL: https://ancode.app/fhir/StructureDefinition/CBOHealthcare Binding: CBOHealthcare (required) | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | Σ | 1..1 | CodeableConcept | Type of performance Binding: BRGrauParticipacao (required) |
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Device) | The reference to the practitioner |
| onBehalfOf | 1..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 1..1 | Reference(Location) | Where the procedure happened |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: BRCID10 (required) |
| bodySite | Σ | 0..1 | CodeableConcept | Target body sites Binding: BRViaAcesso (required) |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet |
| Procedure.status | required | EventStatus |
| Procedure.category | required | BRTecnicaUtilizada |
| Procedure.code | example | ProcedureCodes(SNOMEDCT) |
| Procedure.performer.function | required | BRGrauParticipacao |
| Procedure.reasonCode | required | BRCID10 (a valid code from Classificação Internacional de Doenças - Décima Revisão - CID-10) |
| Procedure.bodySite | required | BRViaAcesso |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | 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.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | 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 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | 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): IETF language tag
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| performedQuantity | 1..1 | Quantity | Extension URL: https://ancode.app/fhir/StructureDefinition/PerformedQuantity | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| 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 | Σ | 1..1 | Reference(ServiceRequest) | A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown 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 | 1..1 | CodeableConcept | Classification of the procedure Binding: BRTecnicaUtilizada (required) | ||||
| code | Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject | Σ | 1..1 | Reference(Patient) | Who the procedure was performed on | ||||
| encounter | Σ | 1..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | Σ | 1..1 | Period | When the procedure was performed | ||||
| id | 0..1 | id | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| start | ΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
| end | ΣC | 1..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| recorder | Σ | 1..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 1..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| cboHealthcare | 1..1 | CodeableConcept | Extension URL: https://ancode.app/fhir/StructureDefinition/CBOHealthcare Binding: CBOHealthcare (required) | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 1..1 | CodeableConcept | Type of performance Binding: BRGrauParticipacao (required) | ||||
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Device) | The reference to the practitioner | ||||
| onBehalfOf | 1..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 1..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: BRCID10 (required) | ||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite | Σ | 0..1 | CodeableConcept | Target body sites Binding: BRViaAcesso (required) | ||||
| 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 | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| 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 | 0..* | Extension | Additional content defined by implementations | |||||
| 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 | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| 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 | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | EventStatus | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
| Procedure.category | required | BRTecnicaUtilizada | ||||
| Procedure.code | example | ProcedureCodes(SNOMEDCT) | ||||
| Procedure.performer.function | required | BRGrauParticipacao | ||||
| Procedure.reasonCode | required | BRCID10 (a valid code from Classificação Internacional de Doenças - Décima Revisão - CID-10) | ||||
| Procedure.bodySite | required | BRViaAcesso | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
Constraints
| Id | Grade | Path(s) | Details | Requirements |
| dom-r4b | warning | Procedure.contained | Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems : ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic) | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Procedure
Other representations of profile: CSV, Excel, Schematron