procedure-request-discharge-summary (ProcedureRequest) | I | ProcedureRequest | There are no (further) constraints on this element Element idProcedureRequest A request for a procedure or diagnostic to be performed Alternate namesdiagnostic request DefinitionA record of a request for diagnostic investigations, treatments, or operations to be performed.
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id | Σ | 1..1 | id | There are no (further) constraints on this element Element idProcedureRequest.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 idProcedureRequest.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 idProcedureRequest.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 idProcedureRequest.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 idProcedureRequest.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 idProcedureRequest.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 | 0..* | Extension | There are no (further) constraints on this element Element idProcedureRequest.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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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedureRequest.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 idProcedureRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
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definition | Σ I | 0..* | Reference(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element idProcedureRequest.definition Protocol or definition Alternate namesprotocol DefinitionProtocol or definition followed by this request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ActivityDefinition | PlanDefinition) Constraints
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basedOn | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idProcedureRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. 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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replaces | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idProcedureRequest.replaces What request replaces DefinitionThe request takes the place of the referenced completed or terminated request(s). 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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requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idProcedureRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all procedure or diagnostic requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedureRequest.status draft | active | suspended | completed | entered-in-error | cancelled DefinitionThe status of the order. The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. The status of a procedure or diagnostic order. RequestStatus (required)Constraints
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intent | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedureRequest.intent proposal | plan | order + DefinitionWhether the request is a proposal, plan, an original order or a reflex order. This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. The kind of procedure or diagnostic request RequestIntent (required)Constraints
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priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedureRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ProcedureRequest should be addressed with respect to other requests. Note that FHIR strings may not exceed 1MB in size If missing, this task should be performed with normal priority Identifies the level of importance to be assigned to actioning the request RequestPriority (required)Constraints
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doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedureRequest.doNotPerform True if procedure should not be performed DefinitionSet this to true if the record is saying that the procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. This element is labeled as a modifier because it indicates that a procedure shouldn't happen, instead of a request for it to happen. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ProcedureRequest.code and ProcedureRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
false
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.category Classification of procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what procedure request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the procedure Procedure Category Codes (SNOMED CT) (example)Constraints
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code | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.code What is being requested/ordered DefinitionA code that identifies a particular procedure, diagnostic investigation, or panel of investigations, that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test ordeer name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code. Unordered, Open, by coding.code(Value) BindingCodes for tests/services that can be performed by procedure or diagnostic services. For laboratory, LOINC is (preferred)[http://hl7.org/fhir/STU3/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). Procedure Codes (SNOMED CT) (example)Constraints
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sliceIdentifierMCDT | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierMCDT What is being requested/ordered DefinitionA code that identifies a particular procedure, diagnostic investigation, or panel of investigations, that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test ordeer name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code. Codes for tests/services that can be performed by procedure or diagnostic services. For laboratory, LOINC is (preferred)[http://hl7.org/fhir/STU3/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). Procedure Codes (SNOMED CT) (example)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierMCDT.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 idProcedureRequest.code:sliceIdentifierMCDT.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..1 | Coding | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierMCDT.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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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierMCDT.coding.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 idProcedureRequest.code:sliceIdentifierMCDT.coding.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 | 0..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierMCDT.coding.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://www.acss.min-saude.pt/2016/10/03/tabelas-meios-complementares-de-diagnostico-e-terapeutica/codigo-convencionado
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierMCDT.coding.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 idProcedureRequest.code:sliceIdentifierMCDT.coding.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 idProcedureRequest.code:sliceIdentifierMCDT.coding.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 idProcedureRequest.code:sliceIdentifierMCDT.coding.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 idProcedureRequest.code:sliceIdentifierMCDT.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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sliceIdentifierSNS | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierSNS What is being requested/ordered DefinitionA code that identifies a particular procedure, diagnostic investigation, or panel of investigations, that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test ordeer name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code. Codes for tests/services that can be performed by procedure or diagnostic services. For laboratory, LOINC is (preferred)[http://hl7.org/fhir/STU3/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). Procedure Codes (SNOMED CT) (example)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierSNS.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 idProcedureRequest.code:sliceIdentifierSNS.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..1 | Coding | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierSNS.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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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierSNS.coding.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 idProcedureRequest.code:sliceIdentifierSNS.coding.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 | 0..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierSNS.coding.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://www.acss.min-saude.pt/2016/10/03/tabelas-meios-complementares-de-diagnostico-e-terapeutica/codigo-sns
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierSNS.coding.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 idProcedureRequest.code:sliceIdentifierSNS.coding.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 idProcedureRequest.code:sliceIdentifierSNS.coding.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 idProcedureRequest.code:sliceIdentifierSNS.coding.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 idProcedureRequest.code:sliceIdentifierSNS.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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sliceIdentifierLOINC | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierLOINC What is being requested/ordered DefinitionA code that identifies a particular procedure, diagnostic investigation, or panel of investigations, that have been requested. Many laboratory and radiology procedure codes embed the specimen/organ system in the test ordeer name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code. Codes for tests/services that can be performed by procedure or diagnostic services. For laboratory, LOINC is (preferred)[http://hl7.org/fhir/STU3/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). Procedure Codes (SNOMED CT) (example)Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierLOINC.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 idProcedureRequest.code:sliceIdentifierLOINC.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..1 | Coding | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierLOINC.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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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierLOINC.coding.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 idProcedureRequest.code:sliceIdentifierLOINC.coding.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 | 0..1 | uriFixed Value | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierLOINC.coding.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.
https://loinc.org
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.code:sliceIdentifierLOINC.coding.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 idProcedureRequest.code:sliceIdentifierLOINC.coding.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 idProcedureRequest.code:sliceIdentifierLOINC.coding.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 idProcedureRequest.code:sliceIdentifierLOINC.coding.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 idProcedureRequest.code:sliceIdentifierLOINC.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 | Σ I | 1..1 | Reference(patient-discharge-summary) | There are no (further) constraints on this element Element idProcedureRequest.subject Individual the service is ordered for DefinitionOn whom or what the procedure or diagnostic is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(patient-discharge-summary) Allowed aggregation: referenced, bundled Constraints
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context | Σ I | 0..1 | Reference(encounter-discharge-summary) | There are no (further) constraints on this element Element idProcedureRequest.context Encounter or Episode during which request was created Alternate namesencounter DefinitionAn encounter or episode of care that provides additional information about the healthcare context in which this request is made. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(encounter-discharge-summary) Allowed aggregation: referenced, bundled Constraints
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occurrencePeriod | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedureRequest.occurrence[x]:occurrencePeriod When procedure should occur Alternate namesschedule DefinitionThe date/time at which the diagnostic testing should occur.
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asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedureRequest.asNeeded[x] Preconditions for procedure or diagnostic DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the procedure. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMED CT Medication As Needed Reason Codes (example)Constraints
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asNeededBoolean | boolean | There are no (further) constraints on this element Data type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedureRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
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requester | Σ | 0..1 | BackboneElement | There are no (further) constraints on this element Element idProcedureRequest.requester Who/what is requesting procedure or diagnostic Alternate namesauthor, orderer DefinitionThe individual who initiated the request and has responsibility for its activation. This not the dispatcher, but rather who is the authorizer.
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id | 0..1 | string | There are no (further) constraints on this element Element idProcedureRequest.requester.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 idProcedureRequest.requester.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 idProcedureRequest.requester.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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agent | Σ I | 1..1 | Reference(practitioner-discharge-summary) | There are no (further) constraints on this element Element idProcedureRequest.requester.agent Individual making the request DefinitionThe device, practitioner or organization who initiated the request. 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(practitioner-discharge-summary) Allowed aggregation: referenced, bundled Constraints
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onBehalfOf | Σ I | 0..1 | Reference(organization-discharge-summary) | There are no (further) constraints on this element Element idProcedureRequest.requester.onBehalfOf Organization agent is 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 authoring the request. 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(organization-discharge-summary) Allowed aggregation: referenced, bundled Constraints
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performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.performerType Performer role DefinitionDesired type of performer for doing the diagnostic testing. this is a role, not a participation type. I.e. does not describe the task, but describes the capacity. For example, “compounding pharmacy” or “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. Participant Roles (example)Constraints
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performer | Σ I | 0..1 | Reference(Practitioner | Organization | Patient | Device | RelatedPerson | HealthcareService) | There are no (further) constraints on this element Element idProcedureRequest.performer Requested perfomer DefinitionThe desired perfomer for doing the diagnostic testing. For example, the surgeon, dermatopathologist, endoscopist, etc. If needed, use an extension for listing alternative performers and/or roles and/or preference. Reference(Practitioner | Organization | Patient | Device | RelatedPerson | HealthcareService) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.reasonCode Explanation/Justification for test DefinitionAn explanation or justification for why this diagnostic investigation is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in supportingInformation. This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the CT Scan example. Diagnosis or problem codes justifying the reason for requesting the procedure or diagnostic investigation. Procedure Reason Codes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation) | There are no (further) constraints on this element Element idProcedureRequest.reasonReference Explanation/Justification for test DefinitionIndicates another resource that provides a justification for why this diagnostic investigation is being requested. May relate to the resources referred to in supportingInformation. This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the CT Scan example. Reference(Condition | Observation) Constraints
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supportingInfo | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idProcedureRequest.supportingInfo Additional clinical information Alternate namesAsk at order entry question, AOE DefinitionAdditional clinical information about the patient or specimen that may influence the procedure or diagnostics or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. 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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specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element idProcedureRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, If the request is entered first with an unknown specimen, The Specimen resource references to the ProcedureRequest.
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bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedureRequest.bodySite Location on Body Alternate nameslocation DefinitionAnatomic location where the procedure should be performed. This is the target site. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Only used if not implicit in the code found in ProcedureRequest.type. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedurerequest-targetBodySite. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element idProcedureRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, letting provider know that "patient hates needles" or other provider instructions. 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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relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element idProcedureRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This may not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
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