{
"description": null,
"_filename": "StructureDefinition-us-core-procedure.json",
"package_name": "hl7.fhir.us.core",
"date": "2016-08-01",
"derivation": "constraint",
"publisher": "Health Level Seven International (FHIR-Infrastructure)",
"name": "US Core Procedure Profile",
"mapping": [ {
"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": "0.0.0",
"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 performed is only permitted if notPerformed indicator is true",
"xpath": "not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true()",
"source": "Procedure",
"severity": "error",
"expression": "reasonNotPerformed.empty() or notPerformed = true"
} ],
"path": "Procedure",
"min": 0,
"definition": "The US Core Condition Profile is based upon the core FHIR Procedure Resource and created to meet the 2015 Edition Common Clinical Data Set 'Procedures' requirements.",
"short": "US Core Procedure Profile",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Procedure[moodCode=EVN]",
"identity": "rim"
}, {
"map": "clinical.general",
"identity": "w5"
} ],
"mustSupport": false,
"sliceName": "USCoreProcedure",
"max": "*",
"id": "Procedure:uscoreprocedure",
"base": {
"max": "*",
"min": 0,
"path": "Procedure"
},
"isSummary": false
}, {
"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",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"type": [ {
"code": "id"
} ],
"max": "1",
"id": "Procedure:uscoreprocedure.id",
"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:uscoreprocedure.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",
"comments": "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 as much as possible.",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "Procedure:uscoreprocedure.implicitRules",
"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",
"comments": "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).",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.language",
"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",
"comments": "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.",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "Procedure:uscoreprocedure.text",
"condition": [ "dom-1" ],
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "Procedure:uscoreprocedure.contained",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
}
}, {
"path": "Procedure.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. 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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure:uscoreprocedure.extension",
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure:uscoreprocedure.modifierExtension",
"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:uscoreprocedure.identifier",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.identifier"
},
"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": "in-progress | aborted | completed | entered-in-error | unknown",
"comments": "The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.",
"mapping": [ {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-status"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.status",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.status"
},
"isSummary": false
}, {
"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",
"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:uscoreprocedure.category",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.category"
},
"isSummary": true
}, {
"path": "Procedure.code",
"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": "SNOMED-CT | ICD-10 | CPT-4",
"mapping": [ {
"map": "OBR-44/OBR-45",
"identity": "v2"
}, {
"map": ".code",
"identity": "rim"
}, {
"map": "what",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"binding": {
"strength": "example",
"description": "A code to identify a specific procedure .",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-code"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.code",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.code"
},
"isSummary": false
}, {
"path": "Procedure.code.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:uscoreprocedure.code.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "Procedure.code.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",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure:uscoreprocedure.code.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "Procedure.code.coding",
"requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.",
"min": 0,
"definition": "A reference to a code defined by a terminology system.",
"short": "Code defined by a terminology system",
"comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.",
"mapping": [ {
"map": "C*E.1-8, C*E.10-22",
"identity": "v2"
}, {
"map": "union(., ./translation)",
"identity": "rim"
}, {
"map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding",
"identity": "orim"
} ],
"slicing": {
"rules": "open",
"discriminator": [ "code" ]
},
"type": [ {
"code": "Coding"
} ],
"max": "*",
"id": "Procedure:uscoreprocedure.code.coding",
"base": {
"max": "*",
"min": 0,
"path": "CodeableConcept.coding"
},
"isSummary": true
}, {
"path": "Procedure.code.coding",
"requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.",
"min": 1,
"definition": "A reference to a code defined by a terminology system.",
"short": "Code defined by a terminology system",
"comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.",
"mapping": [ {
"map": "C*E.1-8, C*E.10-22",
"identity": "v2"
}, {
"map": "union(., ./translation)",
"identity": "rim"
}, {
"map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding",
"identity": "orim"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": true,
"sliceName": "USCoreProcedureCode",
"binding": {
"strength": "required",
"description": "Codes describing the Procedure Type",
"valueSetReference": {
"reference": "http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-type"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.code.coding:uscoreprocedurecode",
"base": {
"max": "*",
"min": 0,
"path": "CodeableConcept.coding"
},
"isSummary": false
}, {
"path": "Procedure.code.coding",
"requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.",
"min": 0,
"definition": "A reference to a code defined by a terminology system.",
"short": "Code defined by a terminology system",
"comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.",
"mapping": [ {
"map": "C*E.1-8, C*E.10-22",
"identity": "v2"
}, {
"map": "union(., ./translation)",
"identity": "rim"
}, {
"map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding",
"identity": "orim"
} ],
"type": [ {
"code": "Coding"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"description": "Optional ICD-10PCS Code translations describing the Procedure Type",
"valueSetReference": {
"reference": "http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-icd10pcs"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.code.coding",
"base": {
"max": "*",
"min": 0,
"path": "CodeableConcept.coding"
},
"isSummary": false
}, {
"path": "Procedure.code.text",
"requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.",
"min": 0,
"definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.",
"short": "Plain text representation of the concept",
"comments": "Very often the text is the same as a displayName of one of the codings.",
"mapping": [ {
"map": "C*E.9. But note many systems use C*E.2 for this",
"identity": "v2"
}, {
"map": "./originalText[mediaType/code=\"text/plain\"]/data",
"identity": "rim"
}, {
"map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText",
"identity": "orim"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "Procedure:uscoreprocedure.code.text",
"base": {
"max": "1",
"min": 0,
"path": "CodeableConcept.text"
},
"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/core/StructureDefinition/us-core-patient"
} ],
"mustSupport": true,
"max": "1",
"id": "Procedure:uscoreprocedure.subject",
"base": {
"max": "1",
"min": 1,
"path": "Procedure.subject"
},
"isSummary": false
}, {
"path": "Procedure.encounter",
"min": 0,
"definition": "The encounter during which the procedure was performed.",
"short": "The encounter 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/StructureDefinition/Encounter"
} ],
"max": "1",
"id": "Procedure:uscoreprocedure.encounter",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.encounter"
},
"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"
} ],
"type": [ {
"code": "dateTime"
}, {
"code": "Period"
} ],
"mustSupport": true,
"max": "1",
"id": "Procedure:uscoreprocedure.performed[x]",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.performed[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "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=PFM]",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"max": "*",
"id": "Procedure:uscoreprocedure.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:uscoreprocedure.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",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure:uscoreprocedure.performer.extension",
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Procedure:uscoreprocedure.performer.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"path": "Procedure.performer.actor",
"min": 0,
"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/StructureDefinition/Practitioner"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
} ],
"max": "1",
"id": "Procedure:uscoreprocedure.performer.actor",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.performer.actor"
},
"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",
"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:uscoreprocedure.performer.role",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.performer.role"
},
"isSummary": true
}, {
"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": "where",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Location"
} ],
"max": "1",
"id": "Procedure:uscoreprocedure.location",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.location"
},
"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",
"comments": "e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.",
"mapping": [ {
"map": ".reasonCode",
"identity": "rim"
}, {
"map": "why",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Condition"
} ],
"max": "*",
"id": "Procedure:uscoreprocedure.reasonReference",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.reasonReference"
},
"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"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"description": "A code that identifies the reason a procedure is required.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-reason"
}
},
"max": "*",
"id": "Procedure:uscoreprocedure.reasonCode",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.reasonCode"
},
"isSummary": true
}, {
"path": "Procedure.notPerformed",
"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",
"comments": "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.",
"mapping": [ {
"map": ".actionNegationInd",
"identity": "rim"
} ],
"type": [ {
"code": "boolean"
} ],
"defaultValueBoolean": false,
"max": "1",
"id": "Procedure:uscoreprocedure.notPerformed",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.notPerformed"
},
"isSummary": true
}, {
"path": "Procedure.reasonNotPerformed",
"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"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"description": "A code that identifies the reason a procedure was not performed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-not-performed-reason"
}
},
"max": "*",
"id": "Procedure:uscoreprocedure.reasonNotPerformed",
"condition": [ "pro-1" ],
"base": {
"max": "*",
"min": 0,
"path": "Procedure.reasonNotPerformed"
}
}, {
"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"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"description": "Codes describing anatomical locations. May include laterality.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/body-site"
}
},
"max": "*",
"id": "Procedure:uscoreprocedure.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",
"comments": "If outcome contains narrative text only, it can be captured using the CodeableConcept.text.",
"mapping": [ {
"map": ".outboundRelationship[typeCode=OUT].target.text",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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:uscoreprocedure.outcome",
"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",
"comments": "There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.",
"mapping": [ {
"map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]",
"identity": "rim"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
} ],
"max": "*",
"id": "Procedure:uscoreprocedure.report",
"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",
"comments": "If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.",
"mapping": [ {
"map": "Need specialization of OUT for this.",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"description": "Codes describing complications that resulted from a procedure.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/condition-code"
}
},
"max": "*",
"id": "Procedure:uscoreprocedure.complication",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.complication"
}
}, {
"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",
"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:uscoreprocedure.followUp",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.followUp"
}
}, {
"id": "Procedure:uscoreprocedure.request",
"max": "1",
"min": 0,
"base": {
"max": "1",
"min": 0,
"path": "Procedure.request"
},
"path": "Procedure.request",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/CarePlan"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/DiagnosticRequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest"
} ],
"short": "A request for this procedure",
"definition": "A reference to a resource that contains details of the request for this procedure."
}, {
"path": "Procedure.notes",
"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:uscoreprocedure.notes",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.notes"
}
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "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",
"type": [ {
"code": "BackboneElement"
} ],
"max": "*",
"id": "Procedure:uscoreprocedure.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:uscoreprocedure.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",
"comments": "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.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "Procedure:uscoreprocedure.focalDevice.extension",
"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",
"comments": "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.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "Procedure:uscoreprocedure.focalDevice.modifierExtension",
"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",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"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:uscoreprocedure.focalDevice.action",
"base": {
"max": "1",
"min": 0,
"path": "Procedure.focalDevice.action"
}
}, {
"id": "Procedure:uscoreprocedure.focalDevice.manipulated",
"max": "1",
"min": 1,
"base": {
"max": "1",
"min": 1,
"path": "Procedure.focalDevice.manipulated"
},
"path": "Procedure.focalDevice.manipulated",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Device"
} ],
"short": "Device that was changed",
"definition": "The device that was manipulated (changed) during the procedure."
}, {
"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",
"comments": "For devices actually implanted or removed, use Procedure.device.",
"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:uscoreprocedure.usedReference",
"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",
"comments": "For devices actually implanted or removed, use Procedure.device.",
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"description": "Codes describing items used during a procedure"
},
"max": "*",
"id": "Procedure:uscoreprocedure.usedCode",
"base": {
"max": "*",
"min": 0,
"path": "Procedure.usedCode"
}
}, {
"id": "Procedure:uscoreprocedure.component",
"max": "*",
"min": 0,
"base": {
"max": "*",
"min": 0,
"path": "Procedure.component"
},
"path": "Procedure.component",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/MedicationAdministration"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Procedure"
}, {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Observation"
} ],
"short": "Events related to the procedure",
"definition": "Identifies medication administrations, other procedures or observations that are related to this procedure."
} ]
},
"status": "draft",
"id": "b6415659-1a57-42ec-bccc-87b7ee2b221a",
"kind": "resource",
"url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure",
"version": null,
"differential": {
"element": [ {
"id": "Procedure:uscoreprocedure",
"path": "Procedure",
"short": "US Core Procedure Profile",
"isSummary": false,
"sliceName": "USCoreProcedure",
"definition": "The US Core Condition Profile is based upon the core FHIR Procedure Resource and created to meet the 2015 Edition Common Clinical Data Set 'Procedures' requirements.",
"isModifier": false,
"mustSupport": false
}, {
"path": "Procedure.status",
"min": 1,
"isModifier": false,
"type": [ {
"code": "code"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/procedure-status"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.status",
"isSummary": false
}, {
"path": "Procedure.code",
"min": 1,
"isModifier": false,
"short": "SNOMED-CT | ICD-10 | CPT-4",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": true,
"max": "1",
"id": "Procedure:uscoreprocedure.code",
"isSummary": false
}, {
"path": "Procedure.code.coding",
"min": 1,
"isModifier": false,
"slicing": {
"rules": "open",
"discriminator": [ "code" ]
},
"type": [ {
"code": "Coding"
} ],
"mustSupport": true,
"sliceName": "USCoreProcedureCode",
"binding": {
"strength": "required",
"description": "Codes describing the Procedure Type",
"valueSetReference": {
"reference": "http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-type"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.code.coding:uscoreprocedurecode",
"isSummary": false
}, {
"path": "Procedure.code.coding",
"min": 0,
"isModifier": false,
"type": [ {
"code": "Coding"
} ],
"mustSupport": true,
"binding": {
"strength": "required",
"description": "Optional ICD-10PCS Code translations describing the Procedure Type",
"valueSetReference": {
"reference": "http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-icd10pcs"
}
},
"max": "1",
"id": "Procedure:uscoreprocedure.code.coding",
"isSummary": false
}, {
"id": "Procedure:uscoreprocedure.subject",
"max": "1",
"min": 1,
"path": "Procedure.subject",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"
} ],
"isSummary": false,
"isModifier": false,
"mustSupport": true
}, {
"id": "Procedure:uscoreprocedure.performed[x]",
"max": "1",
"min": 1,
"path": "Procedure.performed[x]",
"type": [ {
"code": "dateTime"
}, {
"code": "Period"
} ],
"isSummary": false,
"isModifier": false,
"mustSupport": true
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://www.healthit.gov",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Procedure"
}