| MII_PR_Onko_Mamma_Praeoperative_Markierung (Procedure) | C | | Procedure | There are no (further) constraints on this element Element idProcedure Short descriptionAn action that is being or was performed on a patient DefinitionAn action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.
Procedure Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() - dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() - dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty() - dom-6: A resource should have narrative for robust management
text.`div`.exists()
Mappings- rim: Entity. Role, or Act
- workflow: Event
- rim: Procedure[moodCode=EVN]
|
| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.id Short descriptionLogical 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.
string |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta Short descriptionMetadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Meta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.meta.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.meta.extension Short descriptionAdditional 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. 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 can 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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.meta.versionId Short descriptionVersion specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
id Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idProcedure.meta.lastUpdated Short descriptionWhen the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
instant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.meta.source Short descriptionIdentifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idProcedure.meta.profile Short descriptionProfiles this resource claims to conform to DefinitionCommentsIt is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
canonical(StructureDefinition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idProcedure.meta.security Short descriptionSecurity Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding BindingSecurity Labels from the Healthcare Privacy and Security Classification System.
All Security Labels (extensible) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.meta.tag Short descriptionTags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding BindingCodes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
CommonTags (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules Short descriptionA 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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language Short descriptionLanguage 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).
code BindingCommonLanguages (preferred) Binding extensionsConstraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| text | | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text Short descriptionText summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can 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 information is added later.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained Short descriptionContained, 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Resource Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.extension Short descriptionAdditional 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. 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 can 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension Short descriptionExtensions 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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier Short descriptionExternal Identifiers for this procedure DefinitionBusiness identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.
Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.
This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.identifier
- w5: FiveWs.identifier
- v2: Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4
- rim: .id
|
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | There are no (further) constraints on this element Element idProcedure.instantiatesCanonical Short descriptionInstantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.instantiatesCanonical
- rim: .outboundRelationship[typeCode=DEFN].target
|
| instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element idProcedure.instantiatesUri Short descriptionInstantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.instantiatesUri
- rim: .outboundRelationship[typeCode=DEFN].target
|
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | There are no (further) constraints on this element Element idProcedure.basedOn Short descriptionA request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure.
Reference(CarePlan | ServiceRequest) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.basedOn
- rim: .outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
|
| partOf | S Σ | 0..* | Reference(MII_PR_Onko_Operation) | Element idProcedure.partOf Short descriptionPart of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step.
The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).
Reference(MII_PR_Onko_Operation) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.partOf
- rim: .inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
|
| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.status Short descriptionpreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally, this will be the 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.
code BindingA code specifying the state of the procedure.
EventStatus (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.status
- w5: FiveWs.status
- rim: statusCode
|
| statusReason | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.statusReason Short descriptionReason for current status Alternate namesSuspended Reason, Cancelled Reason DefinitionCaptures the reason for the current state of the procedure.
This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.
CodeableConcept BindingA code that identifies the reason a procedure was not performed.
ProcedureNotPerformedReason(SNOMED-CT) (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.statusReason
- rim: .reason.Observation.value
|
| category | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.category Short descriptionClassification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").
CodeableConcept BindingA code that classifies a procedure for searching, sorting and display purposes.
ProcedureCategoryCodes(SNOMEDCT) (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- w5: FiveWs.class
- rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
|
| code | S Σ | 1..1 | CodeableConcept | Element idProcedure.code Short descriptionPräoperative Tumormarkierung Alternate namestype DefinitionPräoperative Markierung von Tumorgewebe in der Brust zur exakten Lokalisation während der Operation
0..1 to account for primarily narrative only resources.
CodeableConcept BindingA code to identify a specific procedure .
ProcedureCodes(SNOMEDCT) (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.code
- w5: FiveWs.what[x]
- v2: OBR-44/OBR-45
- rim: .code
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.extension Short descriptionAdditional 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. 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 can 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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| coding | S Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.code.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text Short descriptionPlain 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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| subject | S Σ | 1..1 | Reference(Patient) | Element idProcedure.subject Short descriptionWho the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed.
Reference(Patient) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.subject
- w5: FiveWs.subject[x]
- v2: PID-3
- rim: .participation[typeCode=SBJ].role
- w5: FiveWs.subject
|
| encounter | S Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idProcedure.encounter Short descriptionEncounter created as part of DefinitionThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
Reference(Encounter) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.context
- w5: FiveWs.context
- v2: PV1-19
- rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
|
| performed[x] | Σ | 0..1 | | There are no (further) constraints on this element Element idProcedure.performed[x] Short descriptionWhen the procedure was performed DefinitionEstimated or actual date, date-time, period, or age when 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.
Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.occurrence[x]
- w5: FiveWs.done[x]
- v2: OBR-7
- rim: .effectiveTime
|
| performedDateTime | | | dateTime | There are no (further) constraints on this element Data typedateTime |
| performedPeriod | | | Period | There are no (further) constraints on this element Data typePeriod |
| performedString | | | string | There are no (further) constraints on this element Data typestring |
| performedAge | | | Age | There are no (further) constraints on this element Data typeAge |
| performedRange | | | Range | There are no (further) constraints on this element Data typeRange |
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idProcedure.recorder Short descriptionWho recorded the procedure DefinitionIndividual who recorded the record and takes responsibility for its content.
Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- w5: FiveWs.author
- rim: .participation[typeCode=AUT].role
|
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idProcedure.asserter Short descriptionPerson who asserts this procedure DefinitionIndividual who is making the procedure statement.
Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- w5: FiveWs.source
- rim: .participation[typeCode=INF].role
|
| performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.performer Short descriptionThe people who performed the procedure DefinitionLimited to "real" people rather than equipment.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.performer
- rim: .participation[typeCode=PRF]
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.extension Short descriptionAdditional 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. 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 can 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| function | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.function Short descriptionType of performance DefinitionDistinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.
Allows disambiguation of the types of involvement of different performers.
CodeableConcept BindingA code that identifies the role of a performer of the procedure.
ProcedurePerformerRoleCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.performer.function
- v2: 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
- rim: .functionCode
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| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | There are no (further) constraints on this element Element idProcedure.performer.actor Short descriptionThe reference to the practitioner DefinitionThe practitioner who was involved in the procedure.
A reference to Device supports use cases, such as pacemakers.
Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.performer.actor
- w5: FiveWs.actor
- v2: ORC-19/PRT-5
- rim: .role
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| onBehalfOf | | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOf Short descriptionOrganization 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.
Reference(Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings |
| location | Σ | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idProcedure.location Short descriptionWhere 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.
Reference(Location) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- w5: FiveWs.where[x]
- rim: .participation[typeCode=LOC].role[classCode=SDLOC]
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| reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.reasonCode Short descriptionCoded reason procedure performed DefinitionThe coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.
Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
CodeableConcept BindingA code that identifies the reason a procedure is required.
ProcedureReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.reasonCode
- w5: FiveWs.why[x]
- rim: .reasonCode
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| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | There are no (further) constraints on this element Element idProcedure.reasonReference Short descriptionThe justification that the procedure was performed DefinitionThe justification of why the procedure was performed.
It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use).
Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.reasonReference
- w5: FiveWs.why[x]
- rim: .reasonCode
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.bodySite Short descriptionTarget body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.
CodeableConcept BindingCodes describing anatomical locations. May include laterality.
SNOMEDCTBodyStructures (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: OBX-20
- rim: .targetSiteCode
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| outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.outcome Short descriptionThe result of procedure DefinitionThe outcome of the procedure - did it resolve the reasons for the procedure being performed?
If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
CodeableConcept BindingAn outcome of a procedure - whether it was resolved or otherwise.
ProcedureOutcomeCodes(SNOMEDCT) (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .outboundRelationship[typeCode=OUT].target.text
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| report | | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | There are no (further) constraints on this element Element idProcedure.report Short descriptionAny 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.
Reference(DiagnosticReport | DocumentReference | Composition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
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| complication | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.complication Short descriptionComplication 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.
CodeableConcept BindingCodes describing complications that resulted from a procedure.
Condition/Problem/DiagnosisCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
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| complicationDetail | | 0..* | Reference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationDetail Short descriptionA 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.
Reference(Condition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
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| followUp | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.followUp Short descriptionInstructions for follow up DefinitionIf the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.
CodeableConcept BindingSpecific follow up required for a procedure e.g. removal of sutures.
ProcedureFollowUpCodes(SNOMEDCT) (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
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| note | | 0..* | Annotation | There are no (further) constraints on this element Element idProcedure.note Short descriptionAdditional information about the procedure DefinitionAny other notes and comments about the procedure.
Annotation Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- workflow: Event.note
- v2: NTE
- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
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| focalDevice | | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice Short descriptionManipulated, implanted, or removed device 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.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .participation[typeCode=DEV].role[classCode=MANU]
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| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extension Short descriptionAdditional 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. 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 can 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of 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.
Extension Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| action | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.action Short descriptionKind of change to device DefinitionThe kind of change that happened to the device during the procedure.
CodeableConcept BindingA kind of change that happened to the device during the procedure.
ProcedureDeviceActionCodes (preferred) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
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| manipulated | | 1..1 | Reference(Device) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated Short descriptionDevice that was changed DefinitionThe device that was manipulated (changed) during the procedure.
Reference(Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .participation[typeCode=DEV].role[classCode=SDLOC]
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| usedReference | | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element idProcedure.usedReference Short descriptionItems 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(Device | Medication | Substance) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: .participation[typeCode=DEV].role[classCode=MANU] or
.participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)
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| usedCode | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.usedCode Short descriptionCoded 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.
CodeableConcept BindingCodes describing items used during a procedure.
FHIRDeviceTypes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- rim: participation[typeCode=Dev].role[classCode=MANU]
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| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.usedCode.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.usedCode.extension Short descriptionAdditional 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. 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 can 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.
Extension SlicingUnordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
Mappings |
| coding | S Σ | 0..* | Coding | Element idProcedure.usedCode.coding Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding SlicingUnordered, Open, by code(Value) Slicing für die Modalität der präoperativen Markierung, sowie für verschiedene Seed-Markierungen Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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| PraeoperativeMarkierung | S Σ | 0..1 | CodingBinding | Element idProcedure.usedCode.coding:PraeoperativeMarkierung Short descriptionCode defined by a terminology system DefinitionA reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding BindingMII_VS_Onko_Mamma_Praeoperative_Markierung_Modalitaet (extensible) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.usedCode.text Short descriptionPlain 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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Mappings- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
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