Transfer of Care R4 Hackathon Implementation Guide

This guidance is under active development by NHS England and content may be added or updated on a regular basis.

Procedures

The Procedures section carries information about the procedures that have been performed on the patient. PRSB Elements should be formatted as subheadings in any HTML sent.

Section Description Card. MRO* FHIR Target and Guidance
Procedures The details of any procedures performed. 0 to 1 Optional Carried in the CodeableConcept of Composition.section.code FHIR element. ValueSet UKCoreCompositionSectionCode
PRSB Element Description Card. MRO* FHIR Target and Guidance
Procedure name The therapeutic or diagnostic procedure performed. 1 only O The procedure name in text and where supported a SNOMED CT concept from 71388002 Procedure (procedure) hierarchy or Procedure with explicit context (situation)129125009. Carried in the FHIR element Procedure.code See Procedure List (Procedure name)
Anatomical site The body site of the procedure 0 to 1 O Text and where supported a SNOMED CT concept to represent the anatomical site carried in Procedure.bodySite.
Laterality Laterality of the procedure 0 to 1 O Text and where supported a SNOMED CT concept to represent the laterality carried in Procedure.bodySite (if part of the pre-coordinated term).
Complications related to procedure Details of any intra-operative complications encountered during the procedure, arising during the patient's stay in the recovery unit or directly attributable to the procedure. 0 to many O Text and where supported a SNOMED CT concept to represent the complication carried in the FHIR element Procedure.complication.
Specific anaesthesia issues Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc. 0 to many O Text and where supported either a SNOMED CT concept or a reference to the Condition Resource to represent the anaesthesia issues carried using the extension Extension-CareConnect-AnaestheticIssues-1.
Comment Any further textual comment to clarify such as statement that information is partial or incomplete. 0 to 1 O Free text
* M=Mandatory R=Required O=Optional

Example Procedures Section

{
    "resourceType": "Composition",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition"
        ]
    },
    "status": "final",
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "373942005",
                "display": "Discharge summary"
            }
        ]
    },
    "subject": {
        "reference": "urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57"
    },
    "encounter": {
        "reference": "urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a"
    },
    "date": "2015-02-17T10:00:00+00:00",
    "author":  [
        {
            "reference": "urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc"
        }
    ],
    "title": "Cardiology Service Discharge Summary",
    "section":  [
        {
            "title": "Procedures",
            "code": {
                "coding":  [
                    {
                        "system": "https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings",
                        "code": "procedures",
                        "display": "Procedures"
                    }
                ]
            },
            "text": {
                "status": "additional",
                "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table width=\"100%\"><tbody><tr><th>Procedure name</th><td>Percutaneous coronary intervention</td></tr><tr><th>Anatomical site</th><td>Right coronary artery structure</td></tr><tr><th>Comment</th><td>Patient successfully underwent angioplasty procedure to place a drug eluting stent.</td></tr></tbody></table></div>"
            },
            "entry":  [
                {
                    "reference": "urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1"
                }
            ]
        }
    ]
}
<Composition xmlns="http://hl7.org/fhir">
    <!--   optional elements removed for readability   -->
    <meta>
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Composition" />
    </meta>
    <status value="final" />
    <type>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="373942005" />
            <display value="Discharge summary" />
        </coding>
    </type>
    <subject>
        <reference value="urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" />
    </subject>
    <encounter>
        <reference value="urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" />
    </encounter>
    <date value="2015-02-17T10:00:00+00:00" />
    <author>
        <reference value="urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc" />
    </author>
    <title value="Cardiology Service Discharge Summary" />
    <section>
        <title value="Procedures" />
        <code>
            <coding>
                <system value="https://fhir.hl7.org.uk/CodeSystem/UKCore-RecordStandardHeadings" />
                <code value="procedures" />
                <display value="Procedures" />
            </coding>
        </code>
        <text>
            <status value="additional" />
            <div xmlns="http://www.w3.org/1999/xhtml"><table width="100%"><tbody><tr><th>Procedure name</th><td>Percutaneous coronary intervention</td></tr><tr><th>Anatomical site</th><td>Right coronary artery structure</td></tr><tr><th>Comment</th><td>Patient successfully underwent angioplasty procedure to place a drug eluting stent.</td></tr></tbody></table></div>
        </text>
        <entry>
            <reference value="urn:uuid:1e04ce96-6e52-4f82-bc26-93c89c5836a1" />
        </entry>
    </section>
</Composition>

Example Coded Resources

This text section should be linked to a UKCore-List profiled resource. E.g.

{
    "resourceType": "List",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-List"
        ]
    },
    "identifier":  [
        {
            "system": "https://tools.ietf.org/html/rfc4122",
            "value": "cdd92a18-ffb2-4e3f-aacf-de0e01bb3120"
        }
    ],
    "status": "current",
    "mode": "snapshot",
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "887171000000109",
                "display": "Procedures"
            }
        ]
    },
    "subject": {
        "reference": "urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57"
    },
    "encounter": {
        "reference": "urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a"
    },
    "source": {
        "reference": "urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc"
    },
    "entry":  [
        {
            "item": {
                "reference": "urn:uuid:6ea2da97-73e2-4507-b7a5-f7c0325021a9"
            }
        }
    ]
}
<List xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-List" />
    </meta>
    <identifier>
        <system value="https://tools.ietf.org/html/rfc4122" />
        <value value="cdd92a18-ffb2-4e3f-aacf-de0e01bb3120" />
    </identifier>
    <status value="current" />
    <mode value="snapshot" />
    <code>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="887171000000109" />
            <display value="Procedures" />
        </coding>
    </code>
    <subject>
        <reference value="urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" />
    </subject>
    <encounter>
        <reference value="urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" />
    </encounter>
    <source>
        <reference value="urn:uuid:6239b7a7-380d-46ff-a1c5-7abc4e68f8bc" />
    </source>
    <entry>
        <item>
            <reference value="urn:uuid:6ea2da97-73e2-4507-b7a5-f7c0325021a9" />
        </item>
    </entry>
</List>


This list linked to a UKCore-Procedure profiled resource. E.g.

{
    "resourceType": "Procedure",
    "meta": {
        "profile":  [
            "https://fhir.hl7.org.uk/StructureDefinition/UKCore-Procedure"
        ]
    },
    "identifier":  [
        {
            "system": "https://tools.ietf.org/html/rfc4122",
            "value": "1f2f7b4e-8a61-4211-95b6-034a9a85df58"
        }
    ],
    "status": "completed",
    "code": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "415070008",
                "display": "Percutaneous coronary intervention"
            }
        ]
    },
    "subject": {
        "reference": "urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57"
    },
    "encounter": {
        "reference": "urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a"
    },
    "bodySite":  [
        {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "13647002",
                    "display": "Right coronary artery structure"
                }
            ]
        }
    ]
}
<Procedure xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="https://fhir.hl7.org.uk/StructureDefinition/UKCore-Procedure" />
    </meta>
    <identifier>
        <system value="https://tools.ietf.org/html/rfc4122" />
        <value value="1f2f7b4e-8a61-4211-95b6-034a9a85df58" />
    </identifier>
    <status value="completed" />
    <code>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="415070008" />
            <display value="Percutaneous coronary intervention" />
        </coding>
    </code>
    <subject>
        <reference value="urn:uuid:31686b67-9f20-4644-9a54-193d2f91de57" />
    </subject>
    <encounter>
        <reference value="urn:uuid:4f36b35a-ad18-4ea9-a3fb-c893f709e88a" />
    </encounter>
    <bodySite>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="13647002" />
            <display value="Right coronary artery structure" />
        </coding>
    </bodySite>
</Procedure>
back to top