Basisprofil Prozedur
Canonical URL: http://fhir.de/StructureDefinition/procedure-de-basis/0.2
| procedure-de-basis-0.2 (Procedure) | C | Procedure | There are no (further) constraints on this element Element idProcedureShort description An action that is being or was performed on a patient DefinitionAn 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.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRulesShort description A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. 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. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language. Binding extensions
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | C | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1, dom-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.extensionShort description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifierShort description External Identifiers for this procedure DefinitionThis 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). Need to allow connection to a wider workflow. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| definition | Σ C | 0..* | Reference(ActivityDefinition | HealthcareService | PlanDefinition) | There are no (further) constraints on this element Element idProcedure.definitionShort description Instantiates protocol or definition DefinitionA protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ActivityDefinition | HealthcareService | PlanDefinition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| basedOn | Σ C | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOnShort description A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(CarePlan | ProcedureRequest | ReferralRequest) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| partOf | Σ C | 0..* | Reference(Observation, deutsches Basisprofil (Version 0.2) | Procedure, Deutsches Basisprofil (Version 0.2) | MedicationAdministration) | Element idProcedure.partOfShort description Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. 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. Reference(Observation, deutsches Basisprofil (Version 0.2) | Procedure, Deutsches Basisprofil (Version 0.2) | MedicationAdministration) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.statusShort description preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally this will be in-progress or completed state. 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. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the procedure. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDoneShort description True if procedure was not performed as scheduled DefinitionSet this to true if the record is saying that the procedure was NOT performed. 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. This element is labeled as a modifier because it indicates that a procedure didn't happen. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
falseMappings
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| notDoneReason | Σ C | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReasonShort description Reason procedure was not performed DefinitionA code indicating why the procedure was not performed. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the reason a procedure was not performed. Procedure Not Performed Reason (SNOMED-CT) (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1, pro-1 Constraints
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| category | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.categoryShort description Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that classifies a procedure for searching, sorting and display purposes. Procedure Category Codes (SNOMED CT) (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.codeShort description Identification of the procedure Alternate namestype DefinitionThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code to identify a specific procedure . Procedure Codes (SNOMED CT) (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.idShort description xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.extensionShort description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| coding | Σ | 0..* | Coding | Element idProcedure.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. 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 labeled as UserSelected = true. Unordered, Open, by system(Value) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| OPS | Σ | 0..* | CodingBinding | Element idProcedure.code.coding:OPSShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. 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 labeled as UserSelected = true. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.idShort description xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.extensionShort description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| version | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:OPS.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.textShort description Plain text representation of the concept DefinitionA 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. 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. Very often the text is the same as a displayName of one of the codings. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 1..1 | Reference(Patient, deutsches Basisprofil (Version 0.2) | Group) | Element idProcedure.subjectShort description Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient, deutsches Basisprofil (Version 0.2) | Group) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| context | Σ C | 0..1 | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element idProcedure.contextShort description Encounter or episode associated with the procedure Alternate namesencounter DefinitionThe encounter during which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Encounter | EpisodeOfCare) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x]Short description Date/Period the procedure was performed DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||||
| performedPeriod | Period | There are no (further) constraints on this element Data type | ||||
| performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.performerShort description The people who performed the procedure DefinitionLimited to 'real' people rather than equipment. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.idShort description xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.extensionShort description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.roleShort description The role the actor was in DefinitionFor example: surgeon, anaethetist, endoscopist. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the role of a performer of the procedure. Procedure Performer Role Codes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| actor | Σ C | 1..1 | Reference(Organisation, deutsches Basisprofil (Version 0.2) | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2) | Device | RelatedPerson) | Element idProcedure.performer.actorShort description The reference to the practitioner DefinitionThe practitioner who was involved in the procedure. A reference to Device supports use cases, such as pacemakers. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Organisation, deutsches Basisprofil (Version 0.2) | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2) | Device | RelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| onBehalfOf | C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOfShort description Organization the device or practitioner was acting for DefinitionThe organization the device or practitioner was acting on behalf of. Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| location | Σ C | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idProcedure.locationShort description Where the procedure happened DefinitionThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Ties a procedure to where the records are likely kept. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.reasonCodeShort description Coded reason procedure performed DefinitionThe coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the reason a procedure is required. Procedure Reason Codes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reasonReference | Σ C | 0..* | Reference(Deutsches Basisprofil einer Condition (Version 0.2) | Observation, deutsches Basisprofil (Version 0.2)) | Element idProcedure.reasonReferenceShort description Condition that is the reason the procedure performed DefinitionThe condition that is the reason why the procedure was performed. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. Reference(Deutsches Basisprofil einer Condition (Version 0.2) | Observation, deutsches Basisprofil (Version 0.2)) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.bodySiteShort description Target body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.outcomeShort description The result of procedure DefinitionThe outcome of the procedure - did it resolve reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text. An outcome of a procedure - whether it was resolved or otherwise. Procedure Outcome Codes (SNOMED CT) (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| report | C | 0..* | Reference(DiagnosticReport) | There are no (further) constraints on this element Element idProcedure.reportShort description Any report resulting from the procedure DefinitionThis could be a histology result, pathology report, surgical report, etc.. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.complicationShort description Complication following the procedure DefinitionAny 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. If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Codes describing complications that resulted from a procedure. Condition/Problem/Diagnosis Codes (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| complicationDetail | C | 0..* | Reference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationDetailShort description A condition that is a result of the procedure DefinitionAny complications that occurred during the procedure, or in the immediate post-performance period. This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.followUpShort description Instructions for follow up DefinitionIf 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Specific follow up required for a procedure e.g. removal of sutures. Procedure Follow up Codes (SNOMED CT) (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| note | 0..* | Annotation | There are no (further) constraints on this element Element idProcedure.noteShort description Additional information about the procedure DefinitionAny other notes about the procedure. E.g. the operative notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDeviceShort description Device changed in procedure DefinitionA 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.idShort description xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Note that FHIR strings may not exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extensionShort description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.actionShort description Kind of change to device DefinitionThe kind of change that happened to the device during the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A kind of change that happened to the device during the procedure. Procedure Device Action Codes (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| manipulated | C | 1..1 | Reference(Device) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulatedShort description Device that was changed DefinitionThe device that was manipulated (changed) during the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| usedReference | C | 0..* | Reference(Medication, deutsches Basisprofil (Version 0.2) | Device | Substance) | Element idProcedure.usedReferenceShort description Items used during procedure DefinitionIdentifies medications, devices and any other substance used as part of the procedure. Used for tracking contamination, etc. For devices actually implanted or removed, use Procedure.device. Reference(Medication, deutsches Basisprofil (Version 0.2) | Device | Substance) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.usedCodeShort description Coded items used during the procedure DefinitionIdentifies coded items that were used as part of the procedure. For devices actually implanted or removed, use Procedure.device. Codes describing items used during a procedure ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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