DwProcedure

Purpose

This resource will provide the documented surgical history for the patient as displayed within the EMR.

idS Σ1..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ1..1instant
sourceΣ1..1uri
profileΣ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
textS1..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierS Σ1..1Identifier
instantiatesCanonicalΣ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)
instantiatesUriΣ0..*uri
basedOnΣ I0..*Reference(CarePlan | ServiceRequest)
partOfΣ I0..*Reference(Procedure | Observation | MedicationAdministration)
statusS Σ ?!1..1codeBinding
statusReasonΣ0..1CodeableConcept
categoryS Σ0..1CodeableConcept
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ0..1uri
versionΣ0..1string
codeS Σ0..1code
displayS Σ0..1string
userSelectedS Σ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ0..1uri
versionΣ0..1string
codeS Σ0..1code
displayS Σ0..1string
userSelectedS Σ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ0..1uri
versionS Σ0..1string
codeS Σ0..1code
displayS Σ0..1string
userSelectedS Σ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ0..1uri
versionΣ0..1string
codeS Σ0..1code
displayS Σ0..1string
userSelectedS Σ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ0..1uri
versionS Σ0..1stringFixed Value
codeS Σ0..1code
displayS Σ0..1string
userSelectedS Σ0..1boolean
textS Σ0..1string
subjectS Σ I1..1Reference(Patient | Group)
encounterS Σ I0..1Reference(Encounter)
id0..1string
dataAbsentReasonS I0..1Extension(code)
performedDateTimedateTime
performedPeriodPeriod
performedStringstring
performedAgeAge
performedRangeRange
recorderΣ I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)
asserterΣ I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
functionΣ0..1CodeableConcept
id0..1string
extensionI0..*Extension
referenceΣ I0..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ1..1string
onBehalfOfI0..1Reference(Organization)
id0..1string
extensionI0..*Extension
referenceΣ I0..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayS Σ0..1string
reasonCodeΣ0..*CodeableConcept
reasonReferenceΣ I0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
id0..1string
extensionI0..*Extension
codingΣ0..*Coding
textS Σ0..1string
id0..1string
extensionI0..*Extension
codingΣ0..*Coding
textS Σ0..1string
reportS I0..*Reference(DiagnosticReport | DocumentReference | Composition)
complication0..*CodeableConcept
complicationDetailI0..*Reference(Condition)
followUp0..*CodeableConcept
noteS0..*Annotation
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
action0..1CodeableConceptBinding
manipulatedI1..1Reference(Device)
usedReferenceI0..*Reference(Device | Medication | Substance)
usedCode0..*CodeableConcept

Usage note

  • .status In a clinical setting the procedures are typically documented after they are completed. Most of the time the status will be completed. However, EMRs do have the ability to set the status to current in which case the FHIR status will be preparation. MA --> FHIR current --> preparation past--> completed

    FHIR MA PSS CHR
    Preparation current
    Completed past

.category When the extract is from MA these will be categorized with the SNOMED code 387713003 Surgical procedure (procedure) for Surgical Hx category

.performer When the name of the provider who performed the procedure is documented in the EMR this will be provided

.location Name of the location at which the procedure was performed when available.

.bodySite Site will be provided if documented in the EMR

Bundle

Procedure

Example

{
      "resourceType": "Procedure",
      "id": "ma-labtestsk1-Procedure-2030412",
      "meta": {
         "source": "urn:telus:emr:ma:labtestsk1",
         "lastUpdated": "2023-05-05T13:03:56.000Z",
         "security": [
            {
               "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
               "code": "N",
               "display": "normal"
            }
         ]
      },
      "identifier": [
         {
            "system": "urn:telus:emr:ma:labtestsk1:Procedure",
            "value": "2030412"
         }
      ],
      "status": "completed",
      "category": {
         "coding": [
            {
               "system": "http://snomed.info/sct",
               "code": "387713003",
               "display": "Surgical procedure",
               "userSelected": false
            }
         ],
         "text": "Surgical Hx"
      },
      "code": {
         "coding": [
            {
               "system": "http://hl7.org/fhir/sid/icd-9-cm",
               "code": "47.01",
               "display": "Laproscopic Cholecystectomy",
               "userSelected": true
            }
         ],
         "text": "Cholecystectomy"
      },
      "subject": {
         "reference": "Patient/ma-labtestsk1-Patient-16787",
         "type": "Patient"
      },
      "performedDateTime": "2004-02-09T00:00:00.000Z",
      "outcome": {
         "text": "Recovered"
      },
      "note": []
   }