Implementierungsleitfaden E-Rechnung

Profil
Anmerkungen zu Must-Support Elementen

ERGRechnungsprozedur (Procedure)

ERGRechnungsprozedur (Procedure)

ERG Rechnungsprozedur

Bestätigungsrelevanz

Invocation of operator '=' failed: Unknown symbol 'capability'

Metadaten

Canonical	https://gematik.de/fhir/erg/StructureDefinition/erg-rechnungsprozedur
Status	active
Version	1.1.0-RC1
Basis	http://hl7.org/fhir/StructureDefinition/Procedure

Inhalt

ERGRechnungsprozedur (Procedure)	I		Procedure	There are no (further) constraints on this element Element id Procedure Short description An action that is being or was performed on a patient Definition An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. Data type Procedure Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event rim: Procedure[moodCode=EVN]
id	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id Procedure.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Procedure.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id Procedure.language Short description Language of the resource content Definition The base language in which the resource is written. Comments 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). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id Procedure.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can 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. Comments 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 information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id Procedure.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These 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. Comments 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May 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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id Procedure.identifier Short description External Identifiers for this procedure Definition Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. Requirements Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. Comments This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.identifier w5: FiveWs.identifier v2: Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4 rim: .id
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire)	There are no (further) constraints on this element Element id Procedure.instantiatesCanonical Short description Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. Data type canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.instantiatesCanonical rim: .outboundRelationship[typeCode=DEFN].target
instantiatesUri	Σ	0..*	uri	There are no (further) constraints on this element Element id Procedure.instantiatesUri Short description Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. Comments This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.instantiatesUri rim: .outboundRelationship[typeCode=DEFN].target
basedOn	Σ	0..*	Reference(CarePlan \| ServiceRequest)	There are no (further) constraints on this element Element id Procedure.basedOn Short description A request for this procedure Alternate names fulfills Definition A reference to a resource that contains details of the request for this procedure. Data type Reference(CarePlan \| ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.basedOn rim: .outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
partOf	Σ	0..*	Reference(Procedure \| Observation \| MedicationAdministration)	There are no (further) constraints on this element Element id Procedure.partOf Short description Part of referenced event Alternate names container Definition A larger event of which this particular procedure is a component or step. Comments The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). Data type Reference(Procedure \| Observation \| MedicationAdministration) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.partOf rim: .inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
status	S Σ ?!	1..1	codeBindingPattern	Element id Procedure.status Short description Status der Prozedur Definition A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. Comments Der Status der Prozedur MUSS vorhanden sein. Data type code Binding A code specifying the state of the procedure. EventStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern completed Mappings workflow: Event.status w5: FiveWs.status rim: statusCode
statusReason	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.statusReason Short description Reason for current status Alternate names Suspended Reason, Cancelled Reason Definition Captures the reason for the current state of the procedure. Comments This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. Data type CodeableConcept Binding A code that identifies the reason a procedure was not performed. ProcedureNotPerformedReason(SNOMED-CT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.statusReason rim: .reason.Observation.value
category	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.category Short description Classification of the procedure Definition A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Data type CodeableConcept Binding A code that classifies a procedure for searching, sorting and display purposes. ProcedureCategoryCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
code	S Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.code Short description Identification of the procedure Alternate names type Definition The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). Requirements 0..1 to account for primarily narrative only resources. Data type CodeableConcept Binding A code to identify a specific procedure . ProcedureCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.code w5: FiveWs.what[x] v2: OBR-44/OBR-45 rim: .code
id		0..1	string	There are no (further) constraints on this element Element id Procedure.code.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.code.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
coding	S Σ	0..*	Coding	Element id Procedure.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
OPS	S Σ	0..1	CodingOPSPattern	Element id Procedure.code.coding:OPS Short description Code und Text nach OPS Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Die Codierung nach OPS SOLL vorhanden sein. Data type CodingOPS Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://fhir.de/CodeSystem/bfarm/ops" } Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding
id		0..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:OPS.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.code.coding:OPS.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
Seitenlokalisation	I	0..1	Extension(Coding)	There are no (further) constraints on this element Element id Procedure.code.coding:OPS.extension:Seitenlokalisation Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. Comments 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. Data type Extension(Coding) Extension URL http://fhir.de/StructureDefinition/seitenlokalisation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
system	S Σ	1..1	uriFixed ValuePattern	Element id Procedure.code.coding:OPS.system Short description System des OPS Code Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments Das System des OPS Code MUSS vorhanden sein. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Fixed value http://fhir.de/CodeSystem/bfarm/ops Mappings v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	1..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:OPS.version Short description Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie Verwendung von OPS ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von OPS ein neues Codesystem darstellt. Comments 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ I	1..1	code	Element id Procedure.code.coding:OPS.code Short description Code nach OPS Definition A 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). Requirements Need to refer to a particular code in the system. Comments Der Code nach OPS SOLL vorhanden sein. Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ops-regex: In code sind nur gültige OPS-Codes ohne Zusätze erlaubt `matches('^[1\|3\|5\|6\|8\|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')` Examples Einfacher OPS-Code 5-470 Mappings v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	S Σ	0..1	string	Element id Procedure.code.coding:OPS.display Short description Text zum OPS Code Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Der Text zum OPS Code SOLL vorhanden sein. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id Procedure.code.coding:OPS.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements 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. Comments 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. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.code.text Short description Plain text representation of the concept Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
subject	S Σ	1..1	Reference(ERGPatient \| Patient)	Element id Procedure.subject Short description Referenz auf die behandelte Person Alternate names patient Definition The person, animal or group on which the procedure was performed. Comments Die Procedure SOLL auf eine zugehörige behandelte Person referenzieren. Data type Reference(ERGPatient \| Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 rim: .participation[typeCode=SBJ].role w5: FiveWs.subject
id		0..1	string	There are no (further) constraints on this element Element id Procedure.subject.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.subject.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element id Procedure.subject.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
type	Σ	0..1	uriBinding	There are no (further) constraints on this element Element id Procedure.subject.type Short description Type the reference refers to (e.g. "Patient") Definition The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). Comments This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Data type uri Binding Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element id Procedure.subject.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation\|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.subject.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
encounter	Σ	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id Procedure.encounter Short description Encounter created as part of Definition The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. Comments This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.context w5: FiveWs.context v2: PV1-19 rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
performed[x]	S Σ	0..1		Element id Procedure.performed[x] Short description OPS Behandlungsdatum oder -zeitraum Definition Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. Comments Entweder das OPS Behandlungsdatum, oder der -zeitraum SOLL vorhanden sein. Sliced: Unordered, Open, by $this(Type) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: .effectiveTime
performedDateTime	S Σ	0..1	dateTime	Element id Procedure.performed[x]:performedDateTime Short description OPS Behandlungsdatum Definition Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. Comments Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: .effectiveTime
performedPeriod	S Σ	0..1	Period	Element id Procedure.performed[x]:performedPeriod Short description OPS Behandlungszeitraum Definition Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. Comments Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: .effectiveTime
recorder	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	There are no (further) constraints on this element Element id Procedure.recorder Short description Who recorded the procedure Definition Individual who recorded the record and takes responsibility for its content. Data type Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.author rim: .participation[typeCode=AUT].role
asserter	Σ	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	There are no (further) constraints on this element Element id Procedure.asserter Short description Person who asserts this procedure Definition Individual who is making the procedure statement. Data type Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.source rim: .participation[typeCode=INF].role
performer	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element id Procedure.performer Short description The people who performed the procedure Definition Limited to "real" people rather than equipment. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer rim: .participation[typeCode=PRF]
id		0..1	string	There are no (further) constraints on this element Element id Procedure.performer.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.performer.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.performer.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
function	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.performer.function Short description Type of performance Definition Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Requirements Allows disambiguation of the types of involvement of different performers. Data type CodeableConcept Binding A code that identifies the role of a performer of the procedure. ProcedurePerformerRoleCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer.function v2: Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25 rim: .functionCode
actor	Σ	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	There are no (further) constraints on this element Element id Procedure.performer.actor Short description The reference to the practitioner Definition The practitioner who was involved in the procedure. Requirements A reference to Device supports use cases, such as pacemakers. Data type Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer.actor w5: FiveWs.actor v2: ORC-19/PRT-5 rim: .role
onBehalfOf		0..1	Reference(Organization)	There are no (further) constraints on this element Element id Procedure.performer.onBehalfOf Short description Organization the device or practitioner was acting for Definition The organization the device or practitioner was acting on behalf of. Requirements Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. Data type Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .scoper
location	Σ	0..1	Reference(Location)	There are no (further) constraints on this element Element id Procedure.location Short description Where the procedure happened Definition The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Requirements Ties a procedure to where the records are likely kept. Data type Reference(Location) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.where[x] rim: .participation[typeCode=LOC].role[classCode=SDLOC]
reasonCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.reasonCode Short description Coded reason procedure performed Definition The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. Comments Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Data type CodeableConcept Binding A code that identifies the reason a procedure is required. ProcedureReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.reasonCode w5: FiveWs.why[x] rim: .reasonCode
reasonReference	Σ	0..*	Reference(Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference)	There are no (further) constraints on this element Element id Procedure.reasonReference Short description The justification that the procedure was performed Definition The justification of why the procedure was performed. Comments It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Data type Reference(Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.reasonReference w5: FiveWs.why[x] rim: .reasonCode
bodySite	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.bodySite Short description Target body sites Definition Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Comments If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX-20 rim: .targetSiteCode
outcome	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.outcome Short description The result of procedure Definition The outcome of the procedure - did it resolve the reasons for the procedure being performed? Comments If outcome contains narrative text only, it can be captured using the CodeableConcept.text. Data type CodeableConcept Binding An outcome of a procedure - whether it was resolved or otherwise. ProcedureOutcomeCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .outboundRelationship[typeCode=OUT].target.text
report		0..*	Reference(DiagnosticReport \| DocumentReference \| Composition)	There are no (further) constraints on this element Element id Procedure.report Short description Any report resulting from the procedure Definition This could be a histology result, pathology report, surgical report, etc. Comments There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports. Data type Reference(DiagnosticReport \| DocumentReference \| Composition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
complication		0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.complication Short description Complication following the procedure Definition Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. Comments If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Data type CodeableConcept Binding Codes describing complications that resulted from a procedure. Condition/Problem/DiagnosisCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
complicationDetail		0..*	Reference(Condition)	There are no (further) constraints on this element Element id Procedure.complicationDetail Short description A condition that is a result of the procedure Definition Any complications that occurred during the procedure, or in the immediate post-performance period. Requirements This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. Data type Reference(Condition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
followUp		0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.followUp Short description Instructions for follow up Definition If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. Data type CodeableConcept Binding Specific follow up required for a procedure e.g. removal of sutures. ProcedureFollowUpCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
note		0..*	Annotation	There are no (further) constraints on this element Element id Procedure.note Short description Additional information about the procedure Definition Any other notes and comments about the procedure. Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.note v2: NTE rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
focalDevice		0..*	BackboneElement	There are no (further) constraints on this element Element id Procedure.focalDevice Short description Manipulated, implanted, or removed device Definition A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .participation[typeCode=DEV].role[classCode=MANU]
id		0..1	string	There are no (further) constraints on this element Element id Procedure.focalDevice.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.focalDevice.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.focalDevice.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
action		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Procedure.focalDevice.action Short description Kind of change to device Definition The kind of change that happened to the device during the procedure. Data type CodeableConcept Binding A kind of change that happened to the device during the procedure. ProcedureDeviceActionCodes (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
manipulated		1..1	Reference(Device)	There are no (further) constraints on this element Element id Procedure.focalDevice.manipulated Short description Device that was changed Definition The device that was manipulated (changed) during the procedure. Data type Reference(Device) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .participation[typeCode=DEV].role[classCode=SDLOC]
usedReference		0..*	Reference(Device \| Medication \| Substance)	There are no (further) constraints on this element Element id Procedure.usedReference Short description Items used during procedure Definition Identifies medications, devices and any other substance used as part of the procedure. Requirements Used for tracking contamination, etc. Comments For devices actually implanted or removed, use Procedure.device. Data type Reference(Device \| Medication \| Substance) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .participation[typeCode=DEV].role[classCode=MANU] or .participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)
usedCode		0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.usedCode Short description Coded items used during the procedure Definition Identifies coded items that were used as part of the procedure. Comments For devices actually implanted or removed, use Procedure.device. Data type CodeableConcept Binding Codes describing items used during a procedure. FHIRDeviceTypes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: participation[typeCode=Dev].role[classCode=MANU]

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="erg-rechnungsprozedur" />
    <url value="https://gematik.de/fhir/erg/StructureDefinition/erg-rechnungsprozedur" />
    <version value="1.1.0-RC1" />
    <name value="ERGRechnungsprozedur" />
    <title value="ERG Rechnungsprozedur" />
    <status value="active" />
    <experimental value="false" />
    <date value="2025-02-28" />
    <publisher value="gematik GmbH" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="http://gematik.de/" />
        </telecom>
    </contact>
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="Procedure" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Procedure" />
    <derivation value="constraint" />
    <differential>
        <element id="Procedure.status">
            <path value="Procedure.status" />
            <short value="Status der Prozedur" />
            <comment value="Der Status der Prozedur MUSS vorhanden sein." />
            <patternCode value="completed" />
            <mustSupport value="true" />
        </element>
        <element id="Procedure.code">
            <path value="Procedure.code" />
            <mustSupport value="true" />
        </element>
        <element id="Procedure.code.coding">
            <path value="Procedure.code.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <mustSupport value="true" />
        </element>
        <element id="Procedure.code.coding:OPS">
            <path value="Procedure.code.coding" />
            <sliceName value="OPS" />
            <short value="Code und Text nach OPS" />
            <comment value="Die Codierung nach OPS SOLL vorhanden sein." />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Coding" />
                <profile value="http://fhir.de/StructureDefinition/CodingOPS" />
            </type>
            <patternCoding>
                <system value="http://fhir.de/CodeSystem/bfarm/ops" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="Procedure.code.coding:OPS.system">
            <path value="Procedure.code.coding.system" />
            <short value="System des OPS Code" />
            <comment value="Das System des OPS Code MUSS vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Procedure.code.coding:OPS.code">
            <path value="Procedure.code.coding.code" />
            <short value="Code nach OPS" />
            <comment value="Der Code nach OPS SOLL vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Procedure.code.coding:OPS.display">
            <path value="Procedure.code.coding.display" />
            <short value="Text zum OPS Code" />
            <comment value="Der Text zum OPS Code SOLL vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Procedure.subject">
            <path value="Procedure.subject" />
            <short value="Referenz auf die behandelte Person" />
            <comment value="Die Procedure SOLL auf eine zugeh&#246;rige behandelte Person referenzieren." />
            <type>
                <code value="Reference" />
                <targetProfile value="https://gematik.de/fhir/erg/StructureDefinition/erg-patient" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Procedure.subject.reference">
            <path value="Procedure.subject.reference" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Procedure.performed[x]">
            <path value="Procedure.performed[x]" />
            <slicing>
                <discriminator>
                    <type value="type" />
                    <path value="$this" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
            <short value="OPS Behandlungsdatum oder -zeitraum" />
            <comment value="Entweder das OPS Behandlungsdatum, oder der -zeitraum SOLL vorhanden sein." />
            <type>
                <code value="dateTime" />
            </type>
            <type>
                <code value="Period" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Procedure.performed[x]:performedDateTime">
            <path value="Procedure.performed[x]" />
            <sliceName value="performedDateTime" />
            <short value="OPS Behandlungsdatum" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="dateTime" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Procedure.performed[x]:performedPeriod">
            <path value="Procedure.performed[x]" />
            <sliceName value="performedPeriod" />
            <short value="OPS Behandlungszeitraum" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Period" />
            </type>
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "erg-rechnungsprozedur",
    "url": "https://gematik.de/fhir/erg/StructureDefinition/erg-rechnungsprozedur",
    "version": "1.1.0-RC1",
    "name": "ERGRechnungsprozedur",
    "title": "ERG Rechnungsprozedur",
    "status": "active",
    "experimental": false,
    "date": "2025-02-28",
    "publisher": "gematik GmbH",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "http://gematik.de/"
                }
            ]
        }
    ],
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "Procedure",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Procedure",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Procedure.status",
                "path": "Procedure.status",
                "short": "Status der Prozedur",
                "comment": "Der Status der Prozedur MUSS vorhanden sein.",
                "patternCode": "completed",
                "mustSupport": true
            },
            {
                "id": "Procedure.code",
                "path": "Procedure.code",
                "mustSupport": true
            },
            {
                "id": "Procedure.code.coding",
                "path": "Procedure.code.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "mustSupport": true
            },
            {
                "id": "Procedure.code.coding:OPS",
                "path": "Procedure.code.coding",
                "sliceName": "OPS",
                "short": "Code und Text nach OPS",
                "comment": "Die Codierung nach OPS SOLL vorhanden sein.",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Coding",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/CodingOPS"
                        ]
                    }
                ],
                "patternCoding": {
                    "system": "http://fhir.de/CodeSystem/bfarm/ops"
                },
                "mustSupport": true
            },
            {
                "id": "Procedure.code.coding:OPS.system",
                "path": "Procedure.code.coding.system",
                "short": "System des OPS Code",
                "comment": "Das System des OPS Code MUSS vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Procedure.code.coding:OPS.code",
                "path": "Procedure.code.coding.code",
                "short": "Code nach OPS",
                "comment": "Der Code nach OPS SOLL vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Procedure.code.coding:OPS.display",
                "path": "Procedure.code.coding.display",
                "short": "Text zum OPS Code",
                "comment": "Der Text zum OPS Code SOLL vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Procedure.subject",
                "path": "Procedure.subject",
                "short": "Referenz auf die behandelte Person",
                "comment": "Die Procedure SOLL auf eine zugehörige behandelte Person referenzieren.",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://gematik.de/fhir/erg/StructureDefinition/erg-patient",
                            "http://hl7.org/fhir/StructureDefinition/Patient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Procedure.subject.reference",
                "path": "Procedure.subject.reference",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Procedure.performed[x]",
                "path": "Procedure.performed[x]",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "type",
                            "path": "$this"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                },
                "short": "OPS Behandlungsdatum oder -zeitraum",
                "comment": "Entweder das OPS Behandlungsdatum, oder der -zeitraum SOLL vorhanden sein.",
                "type":  [
                    {
                        "code": "dateTime"
                    },
                    {
                        "code": "Period"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Procedure.performed[x]:performedDateTime",
                "path": "Procedure.performed[x]",
                "sliceName": "performedDateTime",
                "short": "OPS Behandlungsdatum",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "dateTime"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Procedure.performed[x]:performedPeriod",
                "path": "Procedure.performed[x]",
                "sliceName": "performedPeriod",
                "short": "OPS Behandlungszeitraum",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Period"
                    }
                ],
                "mustSupport": true
            }
        ]
    }
}

ERG Rechnungsprozedur

Constraints/Invarianten

Terminology-Bindings

Anmerkungen zu Must-Support-Feldern

Feldname	Kurzbeschreibung	Hinweise
Procedure.status	Status der Prozedur	Der Status der Prozedur MUSS vorhanden sein.
Procedure.code
Procedure.code.coding
Procedure.code.coding:OPS	Code und Text nach OPS	Die Codierung nach OPS SOLL vorhanden sein.
Procedure.code.coding:OPS.system	System des OPS Code	Das System des OPS Code MUSS vorhanden sein.
Procedure.code.coding:OPS.code	Code nach OPS	Der Code nach OPS SOLL vorhanden sein.
Procedure.code.coding:OPS.display	Text zum OPS Code	Der Text zum OPS Code SOLL vorhanden sein.
Procedure.subject	Referenz auf die behandelte Person	Die Procedure SOLL auf eine zugehörige behandelte Person referenzieren.
Procedure.subject.reference
Procedure.performed[x]	OPS Behandlungsdatum oder -zeitraum	Entweder das OPS Behandlungsdatum, oder der -zeitraum SOLL vorhanden sein.
Procedure.performed[x]:performedDateTime	OPS Behandlungsdatum
Procedure.performed[x]:performedPeriod	OPS Behandlungszeitraum