Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | I | DomainResource | An action that is being or was performed on a patient
Reason not performed is only permitted if notPerformed indicator is true |
|
identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
subject | Σ | 1..1 | Reference( Patient | Group) | Who the procedure was performed on |
status | ?! Σ | 1..1 | code | in-progress | aborted | completed | entered-in-error
ProcedureStatus ( Required) |
category | Σ | 0..1 | CodeableConcept | Classification of the procedure
Procedure Category Codes (SNOMED CT) ( Example) |
code | Σ | 1..1 | CodeableConcept | Identification of the procedure
Procedure Codes (SNOMED CT) ( Example) |
notPerformed | ?! | 0..1 | boolean | True if procedure was not performed as scheduled |
reasonNotPerformed | I | 0..* | CodeableConcept | Reason procedure was not performed
Procedure Not Performed Reason (SNOMED-CT) ( Example) |
bodySite | Σ | 0..* | CodeableConcept | Target body sites
SNOMED CT Body Structures ( Example) |
reason[x] | Σ | 0..1 | Reason procedure performed
Procedure Reason Codes ( Example) |
|
reasonCodeableConcept | CodeableConcept | |||
reasonReference | Reference( Condition) | |||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure |
actor | Σ | 0..1 | Reference( Practitioner | Organization | Patient | RelatedPerson) | The reference to the practitioner |
role | Σ | 0..1 | CodeableConcept | The role the actor was in
Procedure Performer Role Codes ( Example) |
performed[x] | Σ | 0..1 | Date/Period the procedure was performed | |
performedDateTime | dateTime | |||
performedPeriod | Period | |||
encounter | Σ | 0..1 | Reference( Encounter) | The encounter associated with the procedure |
location | Σ | 0..1 | Reference( Location) | Where the procedure happened |
outcome | Σ | 0..1 | CodeableConcept | The result of procedure
Procedure Outcome Codes (SNOMED CT) ( Example) |
report | 0..* | Reference( DiagnosticReport) | Any report resulting from the procedure | |
complication | 0..* | CodeableConcept | Complication following the procedure
Condition/Problem/Diagnosis Codes ( Example) |
|
followUp | 0..* | CodeableConcept | Instructions for follow up
Procedure Follow up Codes (SNOMED CT) ( Example) |
|
request | 0..1 | Reference( CarePlan | DiagnosticOrder | ProcedureRequest | ReferralRequest) | A request for this procedure | |
notes | 0..* | Annotation | Additional information about the procedure | |
focalDevice | 0..* | BackboneElement | Device changed in procedure | |
action | 0..1 | CodeableConcept | Kind of change to device
Procedure Device Action Codes ( Required) |
|
manipulated | 1..1 | Reference( Device) | Device that was changed | |
used | 0..* | Reference( Device | Medication | Substance) | Items used during procedure | |
Documentation for this format |