Profiles & Operations Index > Profile: Procedure

Profile: Procedure

Canonical URL:http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-procedure

Simplifier project page: Procedure (PS-ON)

Derived from: Procedure (R4)

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work

Differential View

idΣ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceΣ0..1uri
profileS Σ1..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
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
categoryΣ0..1CodeableConcept
id0..1string
extensionI0..*Extension
codeSCTCAS Σ0..*Coding (PS-ON)Binding
absentOrUnknownProcedureS Σ0..*Coding (PS-ON)Binding
codeICD9CMΣ0..*Coding (PS-ON)Binding
codeCCIΣ0..*Coding (PS-ON)Binding
textS Σ0..1string
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
encounterΣ I0..1Reference(Encounter)
id0..1string
data-absent-reasonS 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
actorΣ I1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)
onBehalfOfI0..1Reference(Organization)
locationΣ I0..1Reference(Location)
reasonCodeΣ0..*CodeableConcept
reasonReferenceΣ I0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
bodySiteΣ0..*Codeable Concept (PS-ON)Binding
outcomeΣ0..1CodeableConcept
reportI0..*Reference(DiagnosticReport | DocumentReference | Composition)
complication0..*CodeableConcept
complicationDetailI0..*Reference(Condition)
followUp0..*CodeableConcept
note0..*Annotation
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
action0..1CodeableConceptBinding
manipulatedI1..1Reference(Device)
usedReferenceI0..*Reference(Device | Medication | Substance)
usedCode0..*CodeableConcept

Hybrid View

idΣ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceΣ0..1uri
profileS Σ1..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
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
categoryΣ0..1CodeableConcept
id0..1string
extensionI0..*Extension
codeSCTCAS Σ0..*Coding (PS-ON)Binding
absentOrUnknownProcedureS Σ0..*Coding (PS-ON)Binding
codeICD9CMΣ0..*Coding (PS-ON)Binding
codeCCIΣ0..*Coding (PS-ON)Binding
textS Σ0..1string
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
encounterΣ I0..1Reference(Encounter)
id0..1string
data-absent-reasonS 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
actorΣ I1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)
onBehalfOfI0..1Reference(Organization)
locationΣ I0..1Reference(Location)
reasonCodeΣ0..*CodeableConcept
reasonReferenceΣ I0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
bodySiteΣ0..*Codeable Concept (PS-ON)Binding
outcomeΣ0..1CodeableConcept
reportI0..*Reference(DiagnosticReport | DocumentReference | Composition)
complication0..*CodeableConcept
complicationDetailI0..*Reference(Condition)
followUp0..*CodeableConcept
note0..*Annotation
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
action0..1CodeableConceptBinding
manipulatedI1..1Reference(Device)
usedReferenceI0..*Reference(Device | Medication | Substance)
usedCode0..*CodeableConcept

Snapshot View

idΣ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceΣ0..1uri
profileS Σ1..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
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
categoryΣ0..1CodeableConcept
id0..1string
extensionI0..*Extension
codeSCTCAS Σ0..*Coding (PS-ON)Binding
absentOrUnknownProcedureS Σ0..*Coding (PS-ON)Binding
codeICD9CMΣ0..*Coding (PS-ON)Binding
codeCCIΣ0..*Coding (PS-ON)Binding
textS Σ0..1string
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
encounterΣ I0..1Reference(Encounter)
id0..1string
data-absent-reasonS 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
actorΣ I1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)
onBehalfOfI0..1Reference(Organization)
locationΣ I0..1Reference(Location)
reasonCodeΣ0..*CodeableConcept
reasonReferenceΣ I0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
bodySiteΣ0..*Codeable Concept (PS-ON)Binding
outcomeΣ0..1CodeableConcept
reportI0..*Reference(DiagnosticReport | DocumentReference | Composition)
complication0..*CodeableConcept
complicationDetailI0..*Reference(Condition)
followUp0..*CodeableConcept
note0..*Annotation
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
action0..1CodeableConceptBinding
manipulatedI1..1Reference(Device)
usedReferenceI0..*Reference(Device | Medication | Substance)
usedCode0..*CodeableConcept

Table View

Procedure..
Procedure.meta1..
Procedure.meta.profile1..
Procedure.status..
Procedure.codeCodeable Concept (PS-ON)1..
Procedure.code.coding..
Procedure.code.coding..
Procedure.code.coding..
Procedure.code.coding..
Procedure.code.coding..
Procedure.subjectReference(Patient (PS-ON))..
Procedure.subject.reference1..
Procedure.performed[x]1..
Procedure.performed[x].extensionExtension..
Procedure.bodySiteCodeable Concept (PS-ON)..

JSON View

{
    "resourceType": "StructureDefinition",
    "id": "ca-on-ps-profile-procedure",
    "url": "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-procedure",
    "version": "0.11.0",
    "name": "ProcedurePSON",
    "title": "Procedure (PS-ON)",
    "status": "active",
    "date": "2022-10-15T12:00:00+00:00",
    "publisher": "Ontario Health",
    "description": "This profile defines a set of constraints to the FHIR Procedure resource for use in Ontario Patient Summaries (PS-ON).  It refines constraints applied  to the Procedure resource by the PS-CA project, which is informed by the constraints of the [Procedure-UV-IPS profile](http://hl7.org/fhir/uv/ips/StructureDefinition-Procedure-uv-ips.html) and the [Canadian Baseline Profile](http://build.fhir.org/ig/HL7-Canada/ca-baseline/branches/master/StructureDefinition-profile-procedure.html) to allow for cross-border and cross-jurisdiction sharing of History of Procedure information.",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "Procedure",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Procedure",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Procedure.meta",
                "path": "Procedure.meta",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Procedure.meta.profile",
                "path": "Procedure.meta.profile",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Procedure.status",
                "path": "Procedure.status",
                "mustSupport": true
            },
            {
                "id": "Procedure.code",
                "path": "Procedure.code",
                "definition": "Identification of the procedure or recording of \"absence of relevant procedures\" or of \"procedures unknown\".",
                "min": 1,
                "type":  [
                    {
                        "code": "CodeableConcept",
                        "profile":  [
                            "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-codeableconcept"
                        ]
                    }
                ],
                "mustSupport": true,
                "binding": {
                    "strength": "preferred",
                    "valueSet": "https://fhir.infoway-inforoute.ca/ValueSet/procedurecode"
                }
            },
            {
                "id": "Procedure.code.coding",
                "path": "Procedure.code.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "description": "Discriminated by the bound value set",
                    "rules": "open"
                },
                "mustSupport": true
            },
            {
                "id": "Procedure.code.coding:codeSCTCA",
                "path": "Procedure.code.coding",
                "sliceName": "codeSCTCA",
                "short": "Slice for representing SNOMED CT CA codes for primary health care procedures",
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "description": "SNOMED CT Canadian codes to describe Services/Activities performed by Primary Health Care Providers.",
                    "valueSet": "https://fhir.infoway-inforoute.ca/ValueSet/procedurecode"
                }
            },
            {
                "id": "Procedure.code.coding:absentOrUnknownProcedure",
                "path": "Procedure.code.coding",
                "sliceName": "absentOrUnknownProcedure",
                "short": "Optional slice for representing a code for absent problem or for unknown procedure",
                "definition": "Code representing the statement \"absent problem\" or the statement \"procedures unknown\"",
                "mustSupport": true,
                "binding": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
                            "valueString": "absentOrUnknownProcedure"
                        }
                    ],
                    "strength": "required",
                    "description": "A code to identify absent or unknown procedures",
                    "valueSet": "http://hl7.org/fhir/uv/ips/ValueSet/absent-or-unknown-procedures-uv-ips"
                }
            },
            {
                "id": "Procedure.code.coding:codeICD9CM",
                "path": "Procedure.code.coding",
                "sliceName": "codeICD9CM",
                "short": "Slice for representing ICD-9 CM codes for primary health care procedures",
                "binding": {
                    "strength": "required",
                    "description": "Any code from ICD-9 CM.",
                    "valueSet": "http://fhir.infoway-inforoute.ca/io/psca/ValueSet/ICD9CM"
                }
            },
            {
                "id": "Procedure.code.coding:codeCCI",
                "path": "Procedure.code.coding",
                "sliceName": "codeCCI",
                "short": "Slice for representing Canadian Classification of Health Interventions (CCI)  codes for primary health care procedures",
                "binding": {
                    "strength": "required",
                    "valueSet": "http://fhir.infoway-inforoute.ca/io/psca/ValueSet/CCI"
                }
            },
            {
                "id": "Procedure.subject",
                "path": "Procedure.subject",
                "definition": "The person on which the procedure was performed.",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-patient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Procedure.subject.reference",
                "path": "Procedure.subject.reference",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Procedure.performed[x]",
                "path": "Procedure.performed[x]",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Procedure.performed[x].extension:data-absent-reason",
                "path": "Procedure.performed[x].extension",
                "sliceName": "data-absent-reason",
                "short": "performed[x] absence reason",
                "definition": "Provides a reason why the performed is missing.",
                "comment": "Some Canadian implementations cannot guarantee that a procedure performed date will always be available in every instance of legacy data. Any implementors who do not require a performed date be available on every procedure need to be able to produce a dataAbsentReason extension in order to be conformant",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Procedure.bodySite",
                "path": "Procedure.bodySite",
                "comment": "While the IPS-UV specification considers this a MS element, some systems will not have a field directly capturing procedure bodysite, further feedback is required on whether these systems are still expected to be able to demonstrate they can construct the asserter using additional data from the system when developing the patient summary instance. Work is underway to define the pan-Canadian terminology that will be preferred and/or socialized for this element.",
                "type":  [
                    {
                        "code": "CodeableConcept",
                        "profile":  [
                            "http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-codeableconcept"
                        ]
                    }
                ],
                "binding": {
                    "strength": "preferred",
                    "valueSet": "https://fhir.infoway-inforoute.ca/ValueSet/anatomicaloracquiredbodystructurecode"
                }
            }
        ]
    }
}

Usage

The Procedure Resource is used to populate entries in the Procedure section of a Patient Summary.

Notes

.id

  • Definition: Logical id of this artifact
  • used to uniquely identify the resource
  • if a persistent identity for the resource is not available to use when constructing the composition Bundle, a UUID SHOULD be used in this element (with a corresponding value in Bundle.entry.fullUrl)
  • Where .id is populated with a persistent identifier, consumers SHALL NOT expect to be able to resolve the resource and SHALL always use the version of the resource contained in the Bundle to render the composition.

.meta.profile

  • used to declare conformance to this profile
  • populate with a fixed value: http://ontariohealth.ca/fhir/StructureDefinition/ca-on-ps-profile-procedure|0.11.0

.meta.versionId

  • SHALL be populated by the Patient Summary Repository server
  • consuming systems can expect this element to be populated when retrieving patient summary instances from the repository
  • source systems do not need to populate this element prior to submission

.status

  • SHALL be used to indicate the clinical status of the procedure
  • in the context of a patient summary, the status is expected to always be "completed"
  • mustSupport element in international patient summary

.code

  • SHALL be used to either:
    • identify the procedure that was performed, or
    • to explicitly state that the patient has no known or unknown past procedures when the history of procedures section in the patient summary does not contain a procedure
  • in situations where a procedure is present:
    • a description of the procedure SHALL be provided in .text for display
    • a coded value SHOULD also be provided in .coding
  • in situations where a procedure is not present, this SHALL be conveyed using .coding from the prescribed valueSet (NoProceduresInfoUvIps)
    • in situations where the EMR cannot distinguish between no-known and no information about patient procedures, then the code for no information should be used. In the instance where a patient is KNOWN to have no procedures, the no-known code should be used.
  • the "codeSCTCA" slice provides the preferred choice of terminology for this element in Ontario
  • mustSupport element in international patient summary

.subject

  • SHALL provide a .reference to the same Patient resource identified in Composition.subject
  • mustSupport element in international patient summary

.performed

  • SHALL be used to indicate when the procedure in question was performed
  • mustSupport element in international patient summary

.performed.dataAbsentReason

  • NOTE: There is currently a rendering issue with this profile; the dataAbsentReason extension should be rendering under the .performed element
  • If no medications are present (i.e. .code is used to convey absent or unknown), .dataAbsentReason SHALL be set to "not-applicable"
  • If no data is available on when the procedure was performed, dataAbsentReason SHOULD be used to indicate why this information is absent
  • mustSupport element in international patient summary