{
"description": null,
"_filename": "StructureDefinition-qicore-procedure.json",
"package_name": "hl7.fhir.us.qicore",
"date": "2017-08-21T16:00:00+10:00",
"derivation": "constraint",
"publisher": "Health Level Seven International (Clinical Quality Information - QICore)",
"fhirVersion": "3.0.1",
"name": "QICore-Procedure",
"mapping": [ {
"uri": "http://www.healthit.gov/quality-data-model",
"name": "Quality Data Model",
"identity": "qdm"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
}, {
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping",
"identity": "w5"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
} ],
"abstract": false,
"type": "Procedure",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "2.1.0",
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-1",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.text.empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()"
}, {
"key": "pro-1",
"human": "Reason not done is only permitted if notDone indicator is true",
"xpath": "not(exists(f:notDoneReason)) or f:notDone/@value=true()",
"source": "Procedure",
"severity": "error",
"expression": "notDoneReason.empty() or notDone = true"
} ],
"path": "Procedure",
"min": 0,
"definition": "An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.",
"short": "An action that is being or was performed on a patient",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Procedure[moodCode=EVN]",
"identity": "rim"
}, {
"map": "clinical.general",
"identity": "w5"
}, {
"map": "Device, Applied (when Procedure.status=(\"in-progress\"| \"completed\")| Procedure, Performed",
"identity": "qdm"
} ],
"mustSupport": false,
"max": "*",
"id": "Procedure",
"base": {
"max": "*",
"min": 0,
"path": "Procedure"
}
}, {
"path": "Procedure.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"short": "Logical id of this artifact",
"mapping": [ {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").id",
"identity": "qdm"
} ],
"type": [ {
"code": "id"
} ],
"mustSupport": false,
"max": "1",
"id": "Procedure.id",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"path": "Procedure.meta",
"min": 0,
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "Procedure.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"path": "Procedure.implicitRules",
"min": 0,
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "Procedure.implicitRules",
"comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isSummary": true
}, {
"path": "Procedure.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"max": "1",
"id": "Procedure.language",
"comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
}
}, {
"path": "Procedure.text",
"min": 0,
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"short": "Text summary of the resource, for human interpretation",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "Procedure.text",
"condition": [ "dom-1" ],
"comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
}
}, {
"path": "Procedure.contained",
"min": 0,
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "Procedure.contained",
"comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
}
}, {
"path": "Procedure.extension",
"min": 0,
"definition": "An Extension",
"short": "Extension",
"slicing": {
"id": "13",
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "url",
"type": "value"
} ]
},
"type": [ {
"code": "Extension"
} ],
"max": "*",
"id": "Procedure.extension",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
}
}, {
"path": "Procedure.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"mapping": [ {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").anatomicalApproachSite",
"identity": "qdm"
} ],
"type": [ {
"code": "Extension",
"profile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite"
} ],
"mustSupport": false,
"sliceName": "approachBodySite",
"max": "*",
"id": "Procedure.extension:approachbodysite",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])",
"source": "Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "Procedure.extension",
"min": 0,
"definition": "An Extension",
"isModifier": false,
"short": "Extension",
"mapping": [ {
"map": "\"Procedure, Performed\".incisionDatetime",
"identity": "qdm"
} ],
"type": [ {
"code": "Extension",
"profile": "http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime"
} ],
"mustSupport": false,
"sliceName": "incisionDateTime",
"max": "1",
"id": "Procedure.extension:incisiondatetime",
"condition": [ "ele-1" ],
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
}
}, {
"path": "Procedure.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
}
}, {
"path": "Procedure.identifier",
"requirements": "Need to allow connection to a wider workflow.",
"min": 0,
"definition": "This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).",
"short": "External Identifiers for this procedure",
"mapping": [ {
"map": "Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4",
"identity": "v2"
}, {
"map": ".id",
"identity": "rim"
}, {
"map": "id",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "*",
"id": "Procedure.identifier",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.identifier"
},
"isSummary": true
}, {
"path": "Procedure.definition",
"min": 0,
"definition": "A protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure.",
"short": "Instantiates protocol or definition",
"mapping": [ {
"map": ".outboundRelationship[typeCode=DEFN].target",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/PlanDefinition"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ActivityDefinition"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/HealthcareService"
} ],
"max": "*",
"id": "Procedure.definition",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.definition"
},
"isSummary": true
}, {
"path": "Procedure.basedOn",
"min": 0,
"definition": "A reference to a resource that contains details of the request for this procedure.",
"short": "A request for this procedure",
"mapping": [ {
"map": ".outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/CarePlan"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
} ],
"alias": [ "fulfills" ],
"max": "*",
"id": "Procedure.basedOn",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.basedOn"
},
"isSummary": true
}, {
"path": "Procedure.partOf",
"min": 0,
"definition": "A larger event of which this particular procedure is a component or step.",
"short": "Part of referenced event",
"mapping": [ {
"map": ".inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationAdministration"
} ],
"alias": [ "container" ],
"max": "*",
"id": "Procedure.partOf",
"comment": "The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, the anesthesia related medicationAdministration is part of the procedure. For an IV medication administration, the procedure to insert the IV port is part of the medication administration.",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.partOf"
},
"isSummary": true
}, {
"path": "Procedure.status",
"min": 1,
"definition": "A code specifying the state of the procedure. Generally this will be in-progress or completed state.",
"isModifier": true,
"short": "preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown",
"mapping": [ {
"map": "statusCode",
"identity": "rim"
}, {
"map": "status",
"identity": "w5"
}, {
"map": "\"Procedure, Performed\".status",
"identity": "qdm"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureStatus"
} ],
"description": "A code specifying the state of the procedure.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/event-status"
}
},
"max": "1",
"id": "Procedure.status",
"comment": "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.\n\nThis element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.status"
},
"isSummary": true
}, {
"path": "Procedure.notDone",
"min": 0,
"definition": "Set this to true if the record is saying that the procedure was NOT performed.",
"isModifier": true,
"short": "True if procedure was not performed as scheduled",
"mapping": [ {
"map": ".actionNegationInd",
"identity": "rim"
} ],
"type": [ {
"code": "boolean"
} ],
"defaultValueBoolean": false,
"max": "1",
"id": "Procedure.notDone",
"comment": "If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say \"There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome\" as it implies that there *could* have been an appendectomy done at any other time, by any other clinician or with any other outcome.\n\nThis element is labeled as a modifier because it indicates that a procedure didn't happen.",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.notDone"
},
"isSummary": true
}, {
"path": "Procedure.notDoneReason",
"min": 0,
"definition": "A code indicating why the procedure was not performed.",
"short": "Reason procedure was not performed",
"mapping": [ {
"map": ".reason.Observation.value",
"identity": "rim"
}, {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").negationRationale",
"identity": "qdm"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureNegationReason"
} ],
"description": "A code that identifies the reason a procedure was not performed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-not-performed-reason"
}
},
"max": "1",
"id": "Procedure.notDoneReason",
"condition": [ "pro-1" ],
"base": {
"max": "1",
"min": 0,
"path": "Procedure.notDoneReason"
},
"isSummary": true
}, {
"path": "Procedure.category",
"min": 0,
"definition": "A code that classifies the procedure for searching, sorting and display purposes (e.g. \"Surgical Procedure\").",
"short": "Classification of the procedure",
"mapping": [ {
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code",
"identity": "rim"
}, {
"map": "class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureCategory"
} ],
"description": "A code that classifies a procedure for searching, sorting and display purposes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-category"
}
},
"max": "1",
"id": "Procedure.category",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.category"
},
"isSummary": true
}, {
"path": "Procedure.code",
"requirements": "0..1 to account for primarily narrative only resources.",
"min": 1,
"definition": "The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. \"Laparoscopic Appendectomy\").",
"short": "Identification of the procedure",
"mapping": [ {
"map": "OBR-44/OBR-45",
"identity": "v2"
}, {
"map": ".code",
"identity": "rim"
}, {
"map": "what",
"identity": "w5"
}, {
"map": "\"Procedure, Performed\".code",
"identity": "qdm"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "preferred",
"description": "Codes describing the Procedure Type",
"valueSetReference": {
"reference": "http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code"
}
},
"alias": [ "type" ],
"max": "1",
"id": "Procedure.code",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.code"
},
"isSummary": true
}, {
"path": "Procedure.subject",
"min": 1,
"definition": "The person, animal or group on which the procedure was performed.",
"short": "Who the procedure was performed on",
"mapping": [ {
"map": "PID-3",
"identity": "v2"
}, {
"map": ".participation[typeCode=SBJ].role",
"identity": "rim"
}, {
"map": "who.focus",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Group"
} ],
"mustSupport": true,
"alias": [ "patient" ],
"max": "1",
"id": "Procedure.subject",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.subject"
},
"isSummary": true
}, {
"path": "Procedure.context",
"min": 0,
"definition": "The encounter during which the procedure was performed.",
"short": "Encounter or episode associated with the procedure",
"mapping": [ {
"map": "PV1-19",
"identity": "v2"
}, {
"map": ".inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]",
"identity": "rim"
}, {
"map": "context",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Group"
} ],
"mustSupport": true,
"alias": [ "encounter" ],
"max": "1",
"id": "Procedure.context",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.context"
},
"isSummary": true
}, {
"path": "Procedure.performed[x]",
"min": 1,
"definition": "The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.",
"short": "Date/Period the procedure was performed",
"mapping": [ {
"map": "OBR-7",
"identity": "v2"
}, {
"map": ".effectiveTime",
"identity": "rim"
}, {
"map": "when.done",
"identity": "w5"
}, {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").relevantPeriod",
"identity": "qdm"
} ],
"type": [ {
"code": "dateTime"
}, {
"code": "Period"
} ],
"mustSupport": true,
"max": "1",
"id": "Procedure.performed[x]",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.performed[x]"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Procedure.performer",
"min": 0,
"definition": "Limited to 'real' people rather than equipment.",
"short": "The people who performed the procedure",
"mapping": [ {
"map": ".participation[typeCode=PRF]",
"identity": "rim"
}, {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").source",
"identity": "qdm"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": true,
"max": "*",
"id": "Procedure.performer",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.performer"
},
"isSummary": true
}, {
"path": "Procedure.performer.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Procedure.performer.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Procedure.performer.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure.performer.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Procedure.performer.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Procedure.performer.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Procedure.performer.role",
"min": 0,
"definition": "For example: surgeon, anaethetist, endoscopist.",
"short": "The role the actor was in",
"mapping": [ {
"map": "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",
"identity": "v2"
}, {
"map": ".functionCode",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedurePerformerRole"
} ],
"description": "A code that identifies the role of a performer of the procedure.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/performer-role"
}
},
"max": "1",
"id": "Procedure.performer.role",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.performer.role"
},
"isSummary": true
}, {
"path": "Procedure.performer.actor",
"requirements": "A reference to Device supports use cases, such as pacemakers.",
"min": 1,
"definition": "The practitioner who was involved in the procedure.",
"short": "The reference to the practitioner",
"mapping": [ {
"map": "ORC-19/PRT-5",
"identity": "v2"
}, {
"map": ".role",
"identity": "rim"
}, {
"map": "who.actor",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-relatedperson"
} ],
"mustSupport": false,
"max": "1",
"id": "Procedure.performer.actor",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.performer.actor"
},
"isSummary": true
}, {
"path": "Procedure.performer.onBehalfOf",
"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.",
"min": 0,
"definition": "The organization the device or practitioner was acting on behalf of.",
"short": "Organization the device or practitioner was acting for",
"mapping": [ {
"map": ".scoper",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"max": "1",
"id": "Procedure.performer.onBehalfOf",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.performer.onBehalfOf"
}
}, {
"path": "Procedure.location",
"requirements": "Ties a procedure to where the records are likely kept.",
"min": 0,
"definition": "The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.",
"short": "Where the procedure happened",
"mapping": [ {
"map": ".participation[typeCode=LOC].role[classCode=SDLOC]",
"identity": "rim"
}, {
"map": "where",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location"
} ],
"mustSupport": false,
"max": "1",
"id": "Procedure.location",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.location"
},
"isSummary": true
}, {
"path": "Procedure.reasonCode",
"min": 0,
"definition": "The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text.",
"short": "Coded reason procedure performed",
"mapping": [ {
"map": ".reasonCode",
"identity": "rim"
}, {
"map": "why",
"identity": "w5"
}, {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").reason",
"identity": "qdm"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureReason"
} ],
"description": "A code that identifies the reason a procedure is required.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-reason"
}
},
"max": "*",
"id": "Procedure.reasonCode",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.reasonCode"
},
"isSummary": true
}, {
"path": "Procedure.reasonReference",
"min": 0,
"definition": "The condition that is the reason why the procedure was performed.",
"short": "Condition that is the reason the procedure performed",
"mapping": [ {
"map": ".reasonCode",
"identity": "rim"
}, {
"map": "why",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
} ],
"mustSupport": false,
"max": "*",
"id": "Procedure.reasonReference",
"comment": "e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.reasonReference"
},
"isSummary": true
}, {
"path": "Procedure.bodySite",
"min": 0,
"definition": "Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.",
"short": "Target body sites",
"mapping": [ {
"map": "OBX-20",
"identity": "v2"
}, {
"map": ".targetSiteCode",
"identity": "rim"
}, {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").anatomicalLocationSite",
"identity": "qdm"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "BodySite"
} ],
"description": "Codes describing anatomical locations. May include laterality.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/body-site"
}
},
"max": "*",
"id": "Procedure.bodySite",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.bodySite"
},
"isSummary": true
}, {
"path": "Procedure.outcome",
"min": 0,
"definition": "The outcome of the procedure - did it resolve reasons for the procedure being performed?",
"short": "The result of procedure",
"mapping": [ {
"map": ".outboundRelationship[typeCode=OUT].target.text",
"identity": "rim"
}, {
"map": "\"Procedure, Performed\".result",
"identity": "qdm"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureOutcome"
} ],
"description": "An outcome of a procedure - whether it was resolved or otherwise.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-outcome"
}
},
"max": "1",
"id": "Procedure.outcome",
"comment": "If outcome contains narrative text only, it can be captured using the CodeableConcept.text.",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.outcome"
},
"isSummary": true
}, {
"path": "Procedure.report",
"min": 0,
"definition": "This could be a histology result, pathology report, surgical report, etc..",
"short": "Any report resulting from the procedure",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport"
} ],
"mustSupport": true,
"max": "*",
"id": "Procedure.report",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.report"
}
}, {
"path": "Procedure.complication",
"min": 0,
"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.",
"short": "Complication following the procedure",
"mapping": [ {
"map": ".outboundRelationship[typeCode=OUTC].target[classCode=OBS, code=\"complication\", moodCode=EVN].value",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureComplication"
} ],
"description": "Codes describing complications that resulted from a procedure.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
},
"max": "*",
"id": "Procedure.complication",
"comment": "If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.complication"
}
}, {
"path": "Procedure.complicationDetail",
"requirements": "This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.",
"min": 0,
"definition": "Any complications that occurred during the procedure, or in the immediate post-performance period.",
"short": "A condition that is a result of the procedure",
"mapping": [ {
"map": ".outboundRelationship[typeCode=OUTC].target[classCode=OBS, code=\"complication\", moodCode=EVN].value",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
} ],
"max": "*",
"id": "Procedure.complicationDetail",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.complicationDetail"
}
}, {
"path": "Procedure.followUp",
"min": 0,
"definition": "If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.",
"short": "Instructions for follow up",
"mapping": [ {
"map": ".outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureFollowUp"
} ],
"description": "Specific follow up required for a procedure e.g. removal of sutures.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-followup"
}
},
"max": "*",
"id": "Procedure.followUp",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.followUp"
}
}, {
"path": "Procedure.note",
"min": 0,
"definition": "Any other notes about the procedure. E.g. the operative notes.",
"short": "Additional information about the procedure",
"mapping": [ {
"map": "NTE",
"identity": "v2"
}, {
"map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value",
"identity": "rim"
} ],
"type": [ {
"code": "Annotation"
} ],
"max": "*",
"id": "Procedure.note",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.note"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "hasValue() | (children().count() > id.count())"
} ],
"path": "Procedure.focalDevice",
"min": 0,
"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.",
"short": "Device changed in procedure",
"mapping": [ {
"map": ".participation[typeCode=DEV].role[classCode=MANU]",
"identity": "rim"
}, {
"map": "\"Device, Applied\".code",
"identity": "qdm"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"max": "*",
"id": "Procedure.focalDevice",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.focalDevice"
}
}, {
"path": "Procedure.focalDevice.id",
"min": 0,
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "Procedure.focalDevice.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Procedure.focalDevice.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"short": "Additional Content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure.focalDevice.extension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Procedure.focalDevice.modifierExtension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Procedure.focalDevice.modifierExtension",
"comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Procedure.focalDevice.action",
"min": 0,
"definition": "The kind of change that happened to the device during the procedure.",
"short": "Kind of change to device",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"procedure device action\"].value=:procedure device action codes",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DeviceActionKind"
} ],
"description": "A kind of change that happened to the device during the procedure.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/device-action"
}
},
"max": "1",
"id": "Procedure.focalDevice.action",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.focalDevice.action"
}
}, {
"path": "Procedure.focalDevice.manipulated",
"min": 1,
"definition": "The device that was manipulated (changed) during the procedure.",
"short": "Device that was changed",
"mapping": [ {
"map": ".participation[typeCode=DEV].role[classCode=SDLOC]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-device"
} ],
"mustSupport": false,
"max": "1",
"id": "Procedure.focalDevice.manipulated",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.focalDevice.manipulated"
}
}, {
"path": "Procedure.usedReference",
"requirements": "Used for tracking contamination, etc.",
"min": 0,
"definition": "Identifies medications, devices and any other substance used as part of the procedure.",
"short": "Items used during procedure",
"mapping": [ {
"map": ".participation[typeCode=DEV].role[classCode=MANU] or\n.participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Medication"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Substance"
} ],
"max": "*",
"id": "Procedure.usedReference",
"comment": "For devices actually implanted or removed, use Procedure.device.",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.usedReference"
}
}, {
"path": "Procedure.usedCode",
"min": 0,
"definition": "Identifies coded items that were used as part of the procedure.",
"short": "Coded items used during the procedure",
"mapping": [ {
"map": "participation[typeCode=Dev].role[classCode=MANU]",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProcedureUsed"
} ],
"description": "Codes describing items used during a procedure",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/device-kind"
}
},
"max": "*",
"id": "Procedure.usedCode",
"comment": "For devices actually implanted or removed, use Procedure.device.",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.usedCode"
}
} ]
},
"status": "draft",
"id": "b493f9e4-2ce3-422e-b9c2-467fad4c0702",
"kind": "resource",
"url": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure",
"version": "0.1",
"differential": {
"element": [ {
"id": "Procedure",
"path": "Procedure",
"mapping": [ {
"map": "Device, Applied (when Procedure.status=(\"in-progress\"| \"completed\")| Procedure, Performed",
"identity": "qdm"
} ],
"isModifier": false,
"mustSupport": false
}, {
"id": "Procedure.id",
"path": "Procedure.id",
"mapping": [ {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").id",
"identity": "qdm"
} ],
"isModifier": false,
"mustSupport": false
}, {
"path": "Procedure.extension",
"min": 0,
"isModifier": false,
"mapping": [ {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").anatomicalApproachSite",
"identity": "qdm"
} ],
"type": [ {
"code": "Extension",
"profile": "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite"
} ],
"mustSupport": false,
"sliceName": "approachBodySite",
"max": "*",
"id": "Procedure.extension:approachbodysite"
}, {
"path": "Procedure.extension",
"min": 0,
"isModifier": false,
"mapping": [ {
"map": "\"Procedure, Performed\".incisionDatetime",
"identity": "qdm"
} ],
"type": [ {
"code": "Extension",
"profile": "http://hl7.org/fhir/StructureDefinition/procedure-incisionDateTime"
} ],
"mustSupport": false,
"sliceName": "incisionDateTime",
"max": "1",
"id": "Procedure.extension:incisiondatetime"
}, {
"id": "Procedure.status",
"path": "Procedure.status",
"mapping": [ {
"map": "\"Procedure, Performed\".status",
"identity": "qdm"
} ],
"isModifier": false,
"mustSupport": true
}, {
"id": "Procedure.notDoneReason",
"path": "Procedure.notDoneReason",
"mapping": [ {
"map": "(\"Device, Applied\"|\"Procedure, Performed\").negationRationale",
"identity": "qdm"
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}
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"id": "Procedure.subject",
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}, {
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}, {
"code": "Reference",
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}, {
"code": "Reference",
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} ],
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}, {
"id": "Procedure.bodySite",
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"id": "Procedure.outcome",
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} ],
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"mustSupport": false
}, {
"id": "Procedure.report",
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} ],
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"mustSupport": false
} ]
},
"contact": [ {
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"value": "http://hl7.org/special/committees/CQI",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure"
}