Copy of 'GP Connect Data Model | FHIR STU3 Representation'

Notice: This guidance is under active development by NHS England and content may be added or updated on a regular basis.

Profile: CareConnect-Procedure-1

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Reference

Canonical URI: https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Procedure-1

The canonical URI is the stable FHIR identifier for this profile and is not currently available as a browsable web page.

Data model element usage

Element Use CareConnect (STU3) UK Core (R4)
extension(anaestheticIssues)
identifier
definition
basedOn
partOf
status
notDone
notDoneReason
category
code
subject
context
performed[x]
performer
location
reasonCode
reasonReference
bodySite
outcome
report
complication
complicationDetail
followUp
note
focalDevice
usedReference
usedCode

extension(anaestheticIssues)

Usage

Mandatory

Guidance

Details of any adverse reaction to any anaesthetic agents Constraint (ext-1): Must have either extensions or value[x], not both

https://interopen.github.io/careconnect-base-stu3/StructureDefinition-Extension-CareConnect-AnaestheticIssues-1.html

Example

<anaestheticIssues>
    <id value="0054272" />
    <url value="https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-AnaestheticIssues-1" /></url>
    <value>
        <reference value="condition-99sss999"/>
    </value>
 </anaestheticIssues>

identifier

Usage

Required

Guidance

External Id(s) for this record

Example
<identifier>
    <system value="https://foo.bar/id/procedure" />
    <value value="fef26348-ccd1-440b-940e-ba1ec058cf21" />
</identifier>

definition

Usage

Mandatory

Guidance

Instantiates protocol or definition

Reference ( PlanDefinition | ActivityDefinition | HealthcareService )

Example
<definition>
    <reference value="healthcareservice-9929ppp" />
</definition>

basedOn

Usage

Optional

Guidance

A request for this procedure

Reference ( CarePlan | ProcedureRequest | ReferralRequest )

Example
<basedOn>
    <reference value="careplan--procedure-request--referral-request--00123f72" />
</basedOn>

partOf

Usage

Optional

Guidance

Part of referenced event

Reference ( MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1 )

Example
<partOf>
    <reference value="medication-administration-07637tys" />
</partOf>

status

Usage

Optional

Guidance

The status of the procedure

e.g. preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown

Example
    <status>
        <code value="suspended" />
        <display value="suspended" />
    </status>

notDone

Usage

Optional

Guidance

Procedure did not occur - Boolean - True | False

Example
        <notDone value="True" />

notDoneReason

Usage

Optional

Guidance

The status of the family history

https://hl7.org/fhir/stu3/valueset-procedure-not-performed-reason.html

e.g. subject-unknown | withheld | unable-to-obtain | deferred. obtai

Example
    <status>
        <code value="withheld" />
        <display value="withheld " />
    </status>

category

code

Usage

Mandatory

Guidance

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

https://hl7.org/fhir/stu3/valueset-procedure-code.html

Example
<code>
    <coding>
        <system value="http://snomed.info/sct" />
        <code value="119000" />
        <display value="Thoracoscopic partial lobectomy of lung" />
    </coding>
    <text value="No code available" />
</code>

subject

Usage

Optional

Guidance
The person, animal or group on which the procedure was performed.

Reference(Patient | Group)

Example
<subject>
    <reference value="patient-9929alp"/>
</suuject>

context

Usage

Optional

Guidance
The encounter during which the procedure was performed.

Reference(Encounter | EpisodeOfCare)

Example
<context>
    <reference value="encounter-99sss999"/>
</context>

performed[x]

Usage

Required

Guidance

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.

Example
<performed>
    <start value="2022-10-28T13:38:00+00:00" />
    <end value="2022-10-28T13:53:00+00:00" />
</performed>

or

<performed>
    <datetime value="2022-10-28T13:38:00+00:00"/>
</performed>

performer

Usage

For investigations

Required

For diary entries

Optional

Guidance

For investigations

Limited to 'real' people rather than equipment.

Example
<performer>
    <reference>
        <identifier>
            <system value="https://fhir.hl7.org.uk/Id/gmc-number" />
            <value value="000000000" />
            <display value="Test GP" />
        </identifier>
    </reference>
</performer>

For diary entries

A use-case for the performer element has not been defined.

location

Usage

Optional

Guidance
The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Reference(Location)

Example
<location>
    <reference value="location-99sss999"/>
</location>

reasonCode

Usage

Optional

Guidance

The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text.

Example
<code>
    <coding>
        <system value="http://snomed.info/sct" />
        <code value="119000" />
        <display value="Thoracoscopic partial lobectomy of lung" />
    </coding>
    <text value="No code available" />
</code>



---

reasonReference

Usage

Optional

Guidance
Reference ( CareConnect-Observation-1 | CareConnect-Condition-1 )
Example
<reasonReference>
    <reference value="condition--00f39ds" />
</reasonReference>

bodySite

Usage

Optional

Guidance

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Example
<bodySite>
    <coding>
        <system value="https://fhir.hl7.org.uk/STU3/CodeSystem/CareConnect-ConditionCategory-1" />
        <code value="182169008" />
        <display value="Entire elbow joint (body structure)" />
    </coding>
</bodySite>

outcome

Usage

Optional

Guidance

An outcome of a procedure - whether it was resolved or otherwise. (Example)

Example
    <outcome> 
      <text value="removal of the retropharyngeal abscess"/> 
    </outcome>

report

Usage

Optional

Guidance

This could be a histology result, pathology report, surgical report, etc..

Reference ( DiagnosticReport )

Example
<report>
    <reference value="DiagnosticReport-07637tys" />
</report>

complication

Usage

Optional

Guidance

This could be a histology result, pathology report, surgical report, etc..

Reference ( DiagnosticReport )

Example
<code>
    <coding>
        <system value="http://snomed.info/sct" />
        <code value="119000" />
        <display value="Perforated intestine condition"/> 
    </coding>
    <text value="No code available" />
</code>

complicationDetail

Usage

Optional

Guidance
The refernce to the specific condition.

Reference(CareConnect-Condition-1)

Example
<condition>
    <reference value="condition-99sss999"/>
</condition>

followUp

Usage

Optional

Guidance

Categorizes the type of clinical assessment performed.

Example
<code>
    <coding>
        <display value="display description" />
        <code value="18949003" />
        <system value="http://snomed.info/sct" />
        <snomedCT>
            <url value="https://simplifier.net/packages/hl7.fhir.r3.core/3.0.2/files/59529" />
            <extension>
            <valueId value="18949003" />
                <descriptionId value="18949003" />
                <descriptionDisplay value="Description" />
            </extesion>
        </snomedCT>
    </coding>
    <text value="Additional text" />
</code>

note

Usage

Required

Guidance

Any notes relating to the specified specimen.

Example
<note>
    <author>
        <reference value="practitioner-948392" />
    </author>
    <time value="2022-10-13T16:59:00Z" />
    <text>
        Free text... R4 of the FHIR standard supports GitHub Flavoured Markdown (GFM).
    </text>
</note>

focalDevice

Usage

Optional

Guidance

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.

Example

  <focalDevice> 
    <action> 
      <coding> 
        <system value="http://hl7.org/fhir/device-action"/> 
        <code value="implanted"/> 
      </coding> 
    </action> 
    <manipulated> 
      <reference value="Device/example-pacemaker"/> 
    </manipulated> 
  </focalDevice>

usedReference

Usage

Optional

Guidance
Identifies medications, devices and any other substance used as part of the procedure.

Reference ( Device | Substance | CareConnect-Medication-1 )

Example
<usedReference>
    <reference value="devcie-99jjj-9899"/>
</usedReference>

usedCode

Usage

Optional

Guidance

Codes describing items used during a procedure (Example)

<code>
    <coding>
        <system value="http://snomed.info/sct" />
        <code value="5159002" />
        <display value="Physiologic monitoring system, device" />
    </coding>
    <text value="No code available" />
</code>
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