NICE-Procedure
Description
This profile is for sumbitting data to the NICE regarding the performance of procedures in the ICU. Procedure indicates a therapeutic procedure undergone by the patient. If relevant, diagnostic procedures can be listed as well. A procedure can be a simple blood pressure measurement, but also a complex heart surgery.
Click here to go to the NICE-Procedure Simplifier page
NICE data dictionary links
Source
This profile is used to submit procedure related information to the Dutch National Intensive Care Evaluation (NICE). It was derived from the Nictiz Health and Care Information Model (HCIM; Dutch: Zorginformatiebouwsteen or ZIB) Procedure, 2017 release version 3.1
Procedure | I | Procedure | Element idProcedure Procedure Alternate namesVerrichting DefinitionRoot concept of the ProcedureTransfer information model. This root concept contains all data elements of the ProcedureTransfer information model.
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id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.id 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.
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meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language 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. Common Languages (extensible)Constraints
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text 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.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained 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 | I | 1..* | Extension | There are no (further) constraints on this element Element idProcedure.extension 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 Constraints
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procedureMethod | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod The method used to perform the procedure Alternate namesextensions, user content DefinitionThe method used to perform this procedure. Improve definition. Add mappings. http://hl7.org/fhir/StructureDefinition/procedure-method Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.id 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
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extension | I | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.extension 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 Constraints
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url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://hl7.org/fhir/StructureDefinition/procedure-method
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valueCodeableConcept | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.value[x]:valueCodeableConcept ProcedureMethod Alternate namesVerrichtingMethode DefinitionThe method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets. VerrichtingMethodeCodelijst VerrichtingMethodeCodelijst (extensible)Constraints
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Verified | S I | 1..1 | Extension(CodeableConcept) | Element idProcedure.extension:Verified Is the instance validated by a medical professional? Alternate namesextensions, user content DefinitionExtension that is used to indicate whether the entire instance has been validated. Every instance shall be validated by a hospital member / datamanager. However, this is not always feasible in case of automated submission of NICE data elements. This extensions shall be used to indicate the validation status of the instance. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1 Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension 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 Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier 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.
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definition | Σ I | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | There are no (further) constraints on this element Element idProcedure.definition 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(PlanDefinition | ActivityDefinition | HealthcareService) Constraints
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basedOn | Σ I | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOn 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) Sliced:Unordered, Open, by $this.resolve()(Type) Constraints
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request | Σ I | 0..* | Reference(HCIM ProcedureRequest) | There are no (further) constraints on this element Element idProcedure.basedOn:request ProcedureRequest Alternate namesfulfills DefinitionThe ProcedureRequest that contains the details of the request for this procedure, including the requester information located at ProcedureRequest.requester. The ProcedureRequest resource is used to capture the healthcare provider who requested the procedure as stated in the HCIM Procedure. Reference(HCIM ProcedureRequest) Constraints
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partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element idProcedure.partOf 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(Procedure | Observation | MedicationAdministration) Constraints
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status | S Σ ?! | 1..1 | codeBindingFixed Value | Element idProcedure.status completed (must be verified) 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. EventStatus (required)Constraints
completed
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notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDone 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.
false
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notDoneReason | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReason 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)Constraints
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category | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes. In the Basisgegevenset Zorg (BGZ) use case, this is use to search and retrieve Surgical Procedures. 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)Constraints
Example of category code { "coding": [ { "system": "http://snomed.info/sct", "code": "387713003", "display": "Surgical procedure" } ] } Mappings
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code | S Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.code ProcedureType Alternate namestype, VerrichtingType DefinitionThe name of the procedure. As of 1 January 2013, all procedures in the primary process have to be documented with CBV codes. To meet this requirement, the DHD procedure thesaurus (CBV procedures set) is used to code procedures. It is possible that in addition to the CBV procedures set, the NIC will be used for nurse procedures and that a “coded value set” will be introduced for paramedic procedures. 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)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.extension 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 Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.code.coding 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) Constraints
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VerrichtingTypeCodelijst | S Σ | 1..* | CodingBinding | Element idProcedure.code.coding:VerrichtingTypeCodelijst Procedure Alternate namesVerrichtingType, Verrichting DefinitionProcedures in the NICE 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. NICE-ProcedureCodeList ProcedureCodeList (required)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.extension 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 Constraints
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system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.system 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.
http://snomed.info/sct
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.version 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.
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code | Σ | 0..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.code 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
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.display 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
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.userSelected 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text 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.
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subject | S Σ I | 1..1 | Reference(NICE-Patient) | Element idProcedure.subject 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.
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context | S Σ I | 0..1 | Reference(NICE-Encounter) | Element idProcedure.context 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.
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performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x] 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. Unordered, Open, by $this(Type) Constraints
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performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
performedPeriod | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.extension 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 Constraints
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start | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has a end value of 2012-02-03. If the end of the period is missing, it means that the period is ongoing
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performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.performer HealthProfessional | Location::HealthcareProvider Alternate namesUitgevoerdDoor, Locatie DefinitionThe healthcare professional that carried out the procedure. The healthcare center (location) where the procedure was or is carried out. Note: Procedure.location could have been used for mapping the Location::HealthcareProvider. In most anticipated cases this would lead to an empty Location resource except for Location.managingOrganization. For efficiency the mapping has thus been done here. Should a Location::HealthcareProvider with an OrganizationLocation be targeted, then this may be solved using Organization.name 'OrganizationLocation' + Organization.partOf 'HealthcareProvider'
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.extension 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 Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension 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.
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role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.role 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)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.role.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.role.extension 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 Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.performer.role.coding 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 $this(Value) Constraints
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healthProfessionalRole | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idProcedure.performer.role.coding:healthProfessionalRole HealthProfessionalRole Alternate namesZorgverlenerRol DefinitionThe role the healthcare provider fulfils in the healthcare process. For healthcare providers, this could be for example main practitioner, referrer or general practitioner. 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. ZorgverlenerRolCodelijst (required) Constraints
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.role.text 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.
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actor | Σ I | 1..1 | Reference(nl-core-practitioner | nl-core-organization) | There are no (further) constraints on this element Element idProcedure.performer.actor 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(nl-core-practitioner | nl-core-organization) Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.actor.extension 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 Constraints
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practitionerRole | I | 0..1 | Extension(Reference(nl-core-practitionerrole)) | There are no (further) constraints on this element Element idProcedure.performer.actor.extension:practitionerRole Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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(Reference(nl-core-practitionerrole)) Extension URLhttp://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference Constraints
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reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idProcedure.performer.actor.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOf 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.
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location | Σ I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idProcedure.location 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.
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.reasonCode 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)Constraints
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reasonReference | Σ I | 0..* | Reference(HCIM Problem) | There are no (further) constraints on this element Element idProcedure.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.
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bodySite | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.bodySite ProcedureAnatomicalLocation Alternate namesVerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of 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. Anatomical location which is the focus of the procedure. VerrichtingAnatomischeLocatieCodelijst (extensible)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extension 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 Constraints
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ProcedureLaterality | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality ProcedureLaterality Alternate namesextensions, user content DefinitionLaterality adds information about body side to the anatomic location, e.g. left 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. http://nictiz.nl/fhir/StructureDefinition/BodySite-Qualifier Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.extension 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 Constraints
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url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://nictiz.nl/fhir/StructureDefinition/BodySite-Qualifier
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valueCodeableConcept | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.value[x]:valueCodeableConcept BodySite qualifier DefinitionQualifier to refine the anatomical location. These include qualifiers for laterality, relative location, directionality, number, and plane. ProcedureLateralityCodelist ProcedureLateralityCodelist (extensible)Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.bodySite.coding 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.text 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.
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outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.outcome 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)Constraints
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report | I | 0..* | Reference(HCIM TextResult) | There are no (further) constraints on this element Element idProcedure.report Any report resulting from the procedure DefinitionAny report resulting from the procedure. Note that the HCIM TextResultForTransfer-v1.2 has this relationship reversed, so the relationship goes from report to procedure.
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complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.complication 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)Constraints
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complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationDetail 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.
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followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.followUp 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)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element idProcedure.note 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).
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focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extension 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 Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension 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.
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action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.action 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)Constraints
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manipulated | I | 1..1 | Reference(HCIM MedicalDevice Product) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated MedicalDevice Alternate namesMedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. 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(HCIM MedicalDevice Product) Constraints
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usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element idProcedure.usedReference 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(Device | Medication | Substance) Constraints
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usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.usedCode 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 FHIR Device Types (example)Constraints
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Procedure | I | Procedure | Element idProcedure Procedure Alternate namesVerrichting DefinitionRoot concept of the ProcedureTransfer information model. This root concept contains all data elements of the ProcedureTransfer information model.
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id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.id 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.
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meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language 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. Common Languages (extensible)Constraints
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text 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.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained 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 | I | 1..* | Extension | There are no (further) constraints on this element Element idProcedure.extension 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 Constraints
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procedureMethod | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod The method used to perform the procedure Alternate namesextensions, user content DefinitionThe method used to perform this procedure. Improve definition. Add mappings. http://hl7.org/fhir/StructureDefinition/procedure-method Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.id 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
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extension | I | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.extension 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 Constraints
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url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://hl7.org/fhir/StructureDefinition/procedure-method
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valueCodeableConcept | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.value[x]:valueCodeableConcept ProcedureMethod Alternate namesVerrichtingMethode DefinitionThe method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets. VerrichtingMethodeCodelijst VerrichtingMethodeCodelijst (extensible)Constraints
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Verified | S I | 1..1 | Extension(CodeableConcept) | Element idProcedure.extension:Verified Is the instance validated by a medical professional? Alternate namesextensions, user content DefinitionExtension that is used to indicate whether the entire instance has been validated. Every instance shall be validated by a hospital member / datamanager. However, this is not always feasible in case of automated submission of NICE data elements. This extensions shall be used to indicate the validation status of the instance. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1 Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension 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 Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier 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.
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definition | Σ I | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | There are no (further) constraints on this element Element idProcedure.definition 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(PlanDefinition | ActivityDefinition | HealthcareService) Constraints
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basedOn | Σ I | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOn 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) Sliced:Unordered, Open, by $this.resolve()(Type) Constraints
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request | Σ I | 0..* | Reference(HCIM ProcedureRequest) | There are no (further) constraints on this element Element idProcedure.basedOn:request ProcedureRequest Alternate namesfulfills DefinitionThe ProcedureRequest that contains the details of the request for this procedure, including the requester information located at ProcedureRequest.requester. The ProcedureRequest resource is used to capture the healthcare provider who requested the procedure as stated in the HCIM Procedure. Reference(HCIM ProcedureRequest) Constraints
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partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element idProcedure.partOf 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(Procedure | Observation | MedicationAdministration) Constraints
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status | S Σ ?! | 1..1 | codeBindingFixed Value | Element idProcedure.status completed (must be verified) 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. EventStatus (required)Constraints
completed
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notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDone 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.
false
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notDoneReason | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReason 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)Constraints
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category | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes. In the Basisgegevenset Zorg (BGZ) use case, this is use to search and retrieve Surgical Procedures. 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)Constraints
Example of category code { "coding": [ { "system": "http://snomed.info/sct", "code": "387713003", "display": "Surgical procedure" } ] } Mappings
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code | S Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.code ProcedureType Alternate namestype, VerrichtingType DefinitionThe name of the procedure. As of 1 January 2013, all procedures in the primary process have to be documented with CBV codes. To meet this requirement, the DHD procedure thesaurus (CBV procedures set) is used to code procedures. It is possible that in addition to the CBV procedures set, the NIC will be used for nurse procedures and that a “coded value set” will be introduced for paramedic procedures. 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)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.extension 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 Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.code.coding 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) Constraints
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VerrichtingTypeCodelijst | S Σ | 1..* | CodingBinding | Element idProcedure.code.coding:VerrichtingTypeCodelijst Procedure Alternate namesVerrichtingType, Verrichting DefinitionProcedures in the NICE 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. NICE-ProcedureCodeList ProcedureCodeList (required)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.extension 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 Constraints
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system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.system 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.
http://snomed.info/sct
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.version 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.
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code | Σ | 0..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.code 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
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.display 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
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.userSelected 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text 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.
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subject | S Σ I | 1..1 | Reference(NICE-Patient) | Element idProcedure.subject 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.
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context | S Σ I | 0..1 | Reference(NICE-Encounter) | Element idProcedure.context 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.
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performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x] 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. Unordered, Open, by $this(Type) Constraints
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performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
performedPeriod | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.extension 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 Constraints
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start | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has a end value of 2012-02-03. If the end of the period is missing, it means that the period is ongoing
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performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.performer HealthProfessional | Location::HealthcareProvider Alternate namesUitgevoerdDoor, Locatie DefinitionThe healthcare professional that carried out the procedure. The healthcare center (location) where the procedure was or is carried out. Note: Procedure.location could have been used for mapping the Location::HealthcareProvider. In most anticipated cases this would lead to an empty Location resource except for Location.managingOrganization. For efficiency the mapping has thus been done here. Should a Location::HealthcareProvider with an OrganizationLocation be targeted, then this may be solved using Organization.name 'OrganizationLocation' + Organization.partOf 'HealthcareProvider'
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.extension 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 Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension 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.
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role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.role 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)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.role.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.role.extension 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 Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.performer.role.coding 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 $this(Value) Constraints
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healthProfessionalRole | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idProcedure.performer.role.coding:healthProfessionalRole HealthProfessionalRole Alternate namesZorgverlenerRol DefinitionThe role the healthcare provider fulfils in the healthcare process. For healthcare providers, this could be for example main practitioner, referrer or general practitioner. 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. ZorgverlenerRolCodelijst (required) Constraints
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.role.text 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.
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actor | Σ I | 1..1 | Reference(nl-core-practitioner | nl-core-organization) | There are no (further) constraints on this element Element idProcedure.performer.actor 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(nl-core-practitioner | nl-core-organization) Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.actor.extension 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 Constraints
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practitionerRole | I | 0..1 | Extension(Reference(nl-core-practitionerrole)) | There are no (further) constraints on this element Element idProcedure.performer.actor.extension:practitionerRole Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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(Reference(nl-core-practitionerrole)) Extension URLhttp://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference Constraints
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reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idProcedure.performer.actor.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOf 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.
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location | Σ I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idProcedure.location 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.
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.reasonCode 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)Constraints
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reasonReference | Σ I | 0..* | Reference(HCIM Problem) | There are no (further) constraints on this element Element idProcedure.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.
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bodySite | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.bodySite ProcedureAnatomicalLocation Alternate namesVerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of 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. Anatomical location which is the focus of the procedure. VerrichtingAnatomischeLocatieCodelijst (extensible)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extension 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 Constraints
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ProcedureLaterality | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality ProcedureLaterality Alternate namesextensions, user content DefinitionLaterality adds information about body side to the anatomic location, e.g. left 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. http://nictiz.nl/fhir/StructureDefinition/BodySite-Qualifier Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.extension 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 Constraints
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url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://nictiz.nl/fhir/StructureDefinition/BodySite-Qualifier
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valueCodeableConcept | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.value[x]:valueCodeableConcept BodySite qualifier DefinitionQualifier to refine the anatomical location. These include qualifiers for laterality, relative location, directionality, number, and plane. ProcedureLateralityCodelist ProcedureLateralityCodelist (extensible)Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.bodySite.coding 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.text 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.
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outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.outcome 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)Constraints
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report | I | 0..* | Reference(HCIM TextResult) | There are no (further) constraints on this element Element idProcedure.report Any report resulting from the procedure DefinitionAny report resulting from the procedure. Note that the HCIM TextResultForTransfer-v1.2 has this relationship reversed, so the relationship goes from report to procedure.
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complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.complication 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)Constraints
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complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationDetail 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.
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followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.followUp 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)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element idProcedure.note 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).
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focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extension 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 Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension 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.
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action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.action 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)Constraints
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manipulated | I | 1..1 | Reference(HCIM MedicalDevice Product) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated MedicalDevice Alternate namesMedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. 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(HCIM MedicalDevice Product) Constraints
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usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element idProcedure.usedReference 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(Device | Medication | Substance) Constraints
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usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.usedCode 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 FHIR Device Types (example)Constraints
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Procedure | I | Procedure | Element idProcedure Procedure Alternate namesVerrichting DefinitionRoot concept of the ProcedureTransfer information model. This root concept contains all data elements of the ProcedureTransfer information model.
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id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.id 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.
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meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language 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. Common Languages (extensible)Constraints
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text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text 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.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained 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 | I | 1..* | Extension | There are no (further) constraints on this element Element idProcedure.extension 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 Constraints
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procedureMethod | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod The method used to perform the procedure Alternate namesextensions, user content DefinitionThe method used to perform this procedure. Improve definition. Add mappings. http://hl7.org/fhir/StructureDefinition/procedure-method Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.id 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
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extension | I | 0..0 | Extension | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.extension 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 Constraints
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url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://hl7.org/fhir/StructureDefinition/procedure-method
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valueCodeableConcept | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.extension:procedureMethod.value[x]:valueCodeableConcept ProcedureMethod Alternate namesVerrichtingMethode DefinitionThe method or technique that was used to perform the procedure, e.g. approach, lavage, pressuring, ets. VerrichtingMethodeCodelijst VerrichtingMethodeCodelijst (extensible)Constraints
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Verified | S I | 1..1 | Extension(CodeableConcept) | Element idProcedure.extension:Verified Is the instance validated by a medical professional? Alternate namesextensions, user content DefinitionExtension that is used to indicate whether the entire instance has been validated. Every instance shall be validated by a hospital member / datamanager. However, this is not always feasible in case of automated submission of NICE data elements. This extensions shall be used to indicate the validation status of the instance. 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. https://fhir.stichting-nice.nl/STU3/StructureDefinition/NICE-Verified-2022Q1 Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension 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 Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier 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.
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definition | Σ I | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | There are no (further) constraints on this element Element idProcedure.definition 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(PlanDefinition | ActivityDefinition | HealthcareService) Constraints
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basedOn | Σ I | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOn 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) Sliced:Unordered, Open, by $this.resolve()(Type) Constraints
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request | Σ I | 0..* | Reference(HCIM ProcedureRequest) | There are no (further) constraints on this element Element idProcedure.basedOn:request ProcedureRequest Alternate namesfulfills DefinitionThe ProcedureRequest that contains the details of the request for this procedure, including the requester information located at ProcedureRequest.requester. The ProcedureRequest resource is used to capture the healthcare provider who requested the procedure as stated in the HCIM Procedure. Reference(HCIM ProcedureRequest) Constraints
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partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element idProcedure.partOf 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(Procedure | Observation | MedicationAdministration) Constraints
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status | S Σ ?! | 1..1 | codeBindingFixed Value | Element idProcedure.status completed (must be verified) 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. EventStatus (required)Constraints
completed
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notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDone 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.
false
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notDoneReason | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReason 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)Constraints
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category | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes. In the Basisgegevenset Zorg (BGZ) use case, this is use to search and retrieve Surgical Procedures. 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)Constraints
Example of category code { "coding": [ { "system": "http://snomed.info/sct", "code": "387713003", "display": "Surgical procedure" } ] } Mappings
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code | S Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.code ProcedureType Alternate namestype, VerrichtingType DefinitionThe name of the procedure. As of 1 January 2013, all procedures in the primary process have to be documented with CBV codes. To meet this requirement, the DHD procedure thesaurus (CBV procedures set) is used to code procedures. It is possible that in addition to the CBV procedures set, the NIC will be used for nurse procedures and that a “coded value set” will be introduced for paramedic procedures. 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)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.extension 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 Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.code.coding 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) Constraints
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VerrichtingTypeCodelijst | S Σ | 1..* | CodingBinding | Element idProcedure.code.coding:VerrichtingTypeCodelijst Procedure Alternate namesVerrichtingType, Verrichting DefinitionProcedures in the NICE 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. NICE-ProcedureCodeList ProcedureCodeList (required)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.extension 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 Constraints
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system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.system 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.
http://snomed.info/sct
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.version 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.
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code | Σ | 0..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.code 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
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.display 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
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:VerrichtingTypeCodelijst.userSelected 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text 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.
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subject | S Σ I | 1..1 | Reference(NICE-Patient) | Element idProcedure.subject 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.
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context | S Σ I | 0..1 | Reference(NICE-Encounter) | Element idProcedure.context 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.
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performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x] 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. Unordered, Open, by $this(Type) Constraints
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performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
performedPeriod | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.extension 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 Constraints
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start | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.performed[x]:performedPeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has a end value of 2012-02-03. If the end of the period is missing, it means that the period is ongoing
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performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.performer HealthProfessional | Location::HealthcareProvider Alternate namesUitgevoerdDoor, Locatie DefinitionThe healthcare professional that carried out the procedure. The healthcare center (location) where the procedure was or is carried out. Note: Procedure.location could have been used for mapping the Location::HealthcareProvider. In most anticipated cases this would lead to an empty Location resource except for Location.managingOrganization. For efficiency the mapping has thus been done here. Should a Location::HealthcareProvider with an OrganizationLocation be targeted, then this may be solved using Organization.name 'OrganizationLocation' + Organization.partOf 'HealthcareProvider'
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.extension 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 Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension 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.
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role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.role 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)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.role.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.role.extension 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 Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.performer.role.coding 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 $this(Value) Constraints
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healthProfessionalRole | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idProcedure.performer.role.coding:healthProfessionalRole HealthProfessionalRole Alternate namesZorgverlenerRol DefinitionThe role the healthcare provider fulfils in the healthcare process. For healthcare providers, this could be for example main practitioner, referrer or general practitioner. 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. ZorgverlenerRolCodelijst (required) Constraints
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.role.text 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.
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actor | Σ I | 1..1 | Reference(nl-core-practitioner | nl-core-organization) | There are no (further) constraints on this element Element idProcedure.performer.actor 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(nl-core-practitioner | nl-core-organization) Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.actor.extension 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 Constraints
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practitionerRole | I | 0..1 | Extension(Reference(nl-core-practitionerrole)) | There are no (further) constraints on this element Element idProcedure.performer.actor.extension:practitionerRole Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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(Reference(nl-core-practitionerrole)) Extension URLhttp://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference Constraints
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reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idProcedure.performer.actor.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the other resource. This is used when there is no way to reference the other resource directly, either because the entity is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.actor.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOf 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.
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location | Σ I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idProcedure.location 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.
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.reasonCode 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)Constraints
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reasonReference | Σ I | 0..* | Reference(HCIM Problem) | There are no (further) constraints on this element Element idProcedure.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.
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bodySite | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.bodySite ProcedureAnatomicalLocation Alternate namesVerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of 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. Anatomical location which is the focus of the procedure. VerrichtingAnatomischeLocatieCodelijst (extensible)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extension 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 Constraints
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ProcedureLaterality | I | 0..1 | Extension(CodeableConcept) | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality ProcedureLaterality Alternate namesextensions, user content DefinitionLaterality adds information about body side to the anatomic location, e.g. left 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. http://nictiz.nl/fhir/StructureDefinition/BodySite-Qualifier Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.extension 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 Constraints
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url | 1..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.url identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://nictiz.nl/fhir/StructureDefinition/BodySite-Qualifier
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valueCodeableConcept | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.bodySite.extension:ProcedureLaterality.value[x]:valueCodeableConcept BodySite qualifier DefinitionQualifier to refine the anatomical location. These include qualifiers for laterality, relative location, directionality, number, and plane. ProcedureLateralityCodelist ProcedureLateralityCodelist (extensible)Constraints
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coding | Σ | 0..* | Coding | There are no (further) constraints on this element Element idProcedure.bodySite.coding 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.text 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.
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outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.outcome 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)Constraints
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report | I | 0..* | Reference(HCIM TextResult) | There are no (further) constraints on this element Element idProcedure.report Any report resulting from the procedure DefinitionAny report resulting from the procedure. Note that the HCIM TextResultForTransfer-v1.2 has this relationship reversed, so the relationship goes from report to procedure.
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complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.complication 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)Constraints
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complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationDetail 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.
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followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.followUp 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)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element idProcedure.note 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).
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focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id 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
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extension 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 Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension 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.
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action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.action 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)Constraints
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manipulated | I | 1..1 | Reference(HCIM MedicalDevice Product) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated MedicalDevice Alternate namesMedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. 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(HCIM MedicalDevice Product) Constraints
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usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element idProcedure.usedReference 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(Device | Medication | Substance) Constraints
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usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.usedCode 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 FHIR Device Types (example)Constraints
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Mapping FHIR profile NICE data dictionary
Path | identity | map | comment |
---|---|---|---|
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#182 | Mechanical ventilation within 24 hours. |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#181 | Mechanical ventilation on IC admission. |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#50 | Chronic dialysis |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#10 | Acute renal failure |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#52 | Cirrhosis |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#58 | Cardio Pulmonary Resuscitation (CPR) |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#96 | Pre-operative ejection fraction |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#225 | Number of grafts |
Procedure | NICE-Datadictionary-MDS | https://www.stichting-nice.nl/dd/#158 | Internal Mammary Arterial graft |
Procedure | NICE-Datadictionary-KIIC | https://www.stichting-nice.nl/dd/#29 | End of mechanical ventilation |
Procedure | NICE-Datadictionary-KIIC | https://www.stichting-nice.nl/dd/#30 | Start of mechanical ventilation |
Procedure | NICE-Datadictionary-Complicatie | https://www.stichting-nice.nl/dd/#894 | Re-intubation/ re-ventilation |
Procedure | NICE-Datadictionary-Complicatie | https://www.stichting-nice.nl/dd/#413 | Trachea cannula present |
Procedure | NICE-Datadictionary-Complicatie | https://www.stichting-nice.nl/dd/#898 | Central venous catheter in place |
Procedure | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#364 | Respiratory support |
Procedure | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#395 | Special ventilation methods (SOFA) |
Procedure | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#174 | Artificial liver support (SOFA) |
Procedure | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#28 | Cardiac Assist Device (SOFA) |
Procedure | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#378 | Renal replacement therapy, (SOFA) |
Procedure | NICE-Datadictionary-SOFA | https://www.stichting-nice.nl/dd/#156 | Intracranial pressure measurement (SOFA) |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#566 | Continuous EEG monitoring |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#28 | Cardiac support (SOFA) |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#571 | Heart massage or cardioversion |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#573 | ECG monitoring |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#575 | Arterial access |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#578 | Arterial pressure measurement |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#593 | Invasive venous pressure measurement |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#588 | Pulmonary or left atrium catheter |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#597 | Central venous catheter |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#598 | Heart minute volume measurement |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#601 | Ventilation |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#602 | Placement/replacement of artificial airway |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#603 | Bronchial toilet |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#604 | Special forms of ventilation - ECMO |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#605 | Special forms of ventilation - DLV |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#606 | Special forms of ventilation - NO |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#609 | Special forms of ventilation - abdomen |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#610 | Bronchoscopy |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#613 | Liver dialysis |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#614 | Balloon tamponade |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#596 | Scopy |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#615 | RRT by IC nurses |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#616 | RRT by dialysis nurse |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#618 | Urinary tract catheter |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#631 | Thermoregulation |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#632 | Drains |
Procedure | NICE-Datadictionary-Capacity | https://www.stichting-nice.nl/dd/#633 | Hygiene procedures |
Procedure | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#746 | Cardiac Assist Device (Sepsis) |
Procedure | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#734 | Special ventilation methods (Sepsis) |
Procedure | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#748 | Renal replacement therapy |
Procedure | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#741 | Artificial liver support (Sepsis) |
Procedure | NICE-Datadictionary-Sepsis | https://www.stichting-nice.nl/dd/#747 | Intracranial pressure measurement (Sepsis) |
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