HdBe-Procedure
Profile | Description | Status | URL |
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HdBe-Procedure-event | Therapeutic or diagnostic procedure undergone by the patient (the complementary profile HdBe-Procedure-request can be used for therapeutic or diagnostics procedures that the patient will undergo). A procedure can be a simple blood pressure measurement, but also a complex heart surgery. In some care settings, the term treatment is used instead of the term procedure. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-event |
HdBe-Procedure-request | Therapeutic or diagnostic procedure the patient will undergo (the complementary profile HdBe-Procedure-request can be used for therapeutic or diagnostics procedures that the has undergone). A procedure can be a simple blood pressure measurement, but also a complex heart surgery. In some care settings, the term treatment is used instead of the term procedure. | draft | https://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-request |
UML overview profiles
Instructions |
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The CBB Procedure is mapped both to a Procedure profile and a profile on ServiceRequest to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings, with the exception of the Requester concept; this is not relevant for past procedures and has only been mapped to the ServiceRequest profile. The planned and performed procedures can be linked using |
HdBe-Procedure-event
Procedure | I | Procedure | Element IdProcedure Procedure Alternate namesVerrichting DefinitionAn 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. The CBB Procedure is mapped both to a Procedure profile and a profile on ServiceRequest to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings, with the exception of the Requester concept; this is not relevant for past procedures and has only been mapped to the ServiceRequest profile. The planned and performed procedures can be linked using
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extension | I | 0..* | Extension | Element IdProcedure.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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procedureMethod | I | 0..* | Extension(CodeableConcept) | Element IdProcedure.extension:procedureMethod The method used to perform the procedure Alternate namesextensions, user content DefinitionThe method used to perform this procedure. 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. https://fhir.healthdata.be/StructureDefinition/ext-Procedure.ProcedureMethod Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdProcedure.identifier External Identifiers for this procedure DefinitionBusiness 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. Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. 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.
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instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | There are no (further) constraints on this element Element IdProcedure.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe 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. canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Constraints
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instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdProcedure.instantiatesUri Instantiates external protocol or definition DefinitionThe 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. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | HdBe Procedure request) | Element IdProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. The root element provides more information on the usage of Reference(CarePlan | ServiceRequest | HdBe Procedure request) Constraints
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partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element IdProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. 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). Reference(Procedure | Observation | MedicationAdministration) Constraints
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status | Σ ?! | 1..1 | codeBinding | Element IdProcedure.status preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown DefinitionThis element is implictly mapped to the concepts ProcedureStartDate and ProcedureEndDate. Unless the status is explicitly recorded, the following guidance applies:
The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the procedure. EventStatus (required)Constraints
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statusReason | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.statusReason Reason for current status Alternate namesSuspended Reason, Cancelled Reason DefinitionCaptures the reason for the current state of the procedure. 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. A code that identifies the reason a procedure was not performed. ProcedureNotPerformedReason(SNOMED-CT) (example)Constraints
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category | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that classifies a procedure for searching, sorting and display purposes. ProcedureCategoryCodes(SNOMEDCT) (example)Constraints
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code | Σ | 0..1 | CodeableConceptBinding | Element IdProcedure.code ProcedureType Alternate namestype, VerrichtingType DefinitionThe name of the procedure. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code to identify a specific procedure . ProcedureType (extensible)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdProcedure.encounter Encounter created as part of DefinitionThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. 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.
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performed[x] | Σ | 0..1 | Element IdProcedure.performed[x] When the procedure was performed DefinitionEstimated 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. 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. Unordered, Open, by $this(Type) Constraints
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performedString | string | There are no (further) constraints on this element Data Type | ||
performedAge | Age | There are no (further) constraints on this element Data Type | ||
performedRange | Range | There are no (further) constraints on this element Data Type | ||
performedPeriod | Σ | 0..1 | Period | Element IdProcedure.performed[x]:performedPeriod When the procedure was performed DefinitionEstimated 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. 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.
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start | Σ I | 0..1 | dateTime | Element IdProcedure.performed[x]:performedPeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | Element IdProcedure.performed[x]:performedPeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
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performedDateTime | Σ | 0..1 | dateTime | Element IdProcedure.performed[x]:performedDateTime ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. 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.
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recorder | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdProcedure.recorder Who recorded the procedure DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints
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asserter | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdProcedure.asserter Person who asserts this procedure DefinitionIndividual who is making the procedure statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints
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performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdProcedure.performer The people who performed the procedure DefinitionLimited to "real" people rather than equipment.
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function | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.performer.function Type of performance DefinitionDistinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Allows disambiguation of the types of involvement of different performers. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the role of a performer of the procedure. ProcedurePerformerRoleCodes (example)Constraints
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actor | Σ I | 1..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdProcedure.performer.actor Performer Alternate namesUitvoerder DefinitionThe health professional who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. A reference to Device supports use cases, such as pacemakers. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
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onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdProcedure.performer.onBehalfOf Organization the device or practitioner was acting for DefinitionThe organization the device or practitioner was acting on behalf of. Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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location | Σ I | 0..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdProcedure.location Location Alternate namesLocatie DefinitionThe healthcare provider where the procedure was, is or or will be carried out. Ties a procedure to where the records are likely kept. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | HdBe HealthcareOrganization) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.reasonCode Coded reason procedure performed DefinitionThe coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. 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. A code that identifies the reason a procedure is required. ProcedureReasonCodes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference | HdBe Problem) | Element IdProcedure.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. 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. Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference | HdBe Problem) Constraints
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bodySite | Σ | 0..1 | HdBe AnatomicalLocationBinding | Element IdProcedure.bodySite Location / ProcedureAnatomicalLocation Alternate namesLocatie, VerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. Location (required)Constraints
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outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.outcome The result of procedure DefinitionThe outcome of the procedure - did it resolve the reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text. An outcome of a procedure - whether it was resolved or otherwise. ProcedureOutcomeCodes(SNOMEDCT) (example)Constraints
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report | I | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Element IdProcedure.report Any report resulting from the procedure DefinitionThis could be a histology result, pathology report, surgical report, etc. 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. Reference(DiagnosticReport | DocumentReference | Composition) Sliced:Unordered, Open, by resolve()(Profile) Constraints
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textResult | I | 0..* | Reference(https://fhir.healthdata.be/StructureDefinition/HdBe-TextResult) | Element IdProcedure.report:textResult TextResult Alternate namesTekstUitslag DefinitionThis could be a histology result, pathology report, surgical report, etc. The direction of the reference between CBBs TextResult and Procedure is reversed in FHIR. Therefore the concept Procedure of zib TextResult is mapped to this element. Please note that on a functional level, TextResult references Procedure, but in FHIR this direction is reversed. Reference(https://fhir.healthdata.be/StructureDefinition/HdBe-TextResult) Constraints
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complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.complication Complication following the procedure DefinitionAny 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. If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Codes describing complications that resulted from a procedure. Condition/Problem/DiagnosisCodes (example)Constraints
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complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element IdProcedure.complicationDetail A condition that is a result of the procedure DefinitionAny complications that occurred during the procedure, or in the immediate post-performance period. This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.followUp Instructions for follow up DefinitionIf 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Specific follow up required for a procedure e.g. removal of sutures. ProcedureFollowUpCodes(SNOMEDCT) (example)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdProcedure.note Additional information about the procedure DefinitionAny other notes and comments about the procedure. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element IdProcedure.focalDevice Manipulated, implanted, or removed device DefinitionA 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.
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action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdProcedure.focalDevice.action Kind of change to device DefinitionThe kind of change that happened to the device during the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A kind of change that happened to the device during the procedure. ProcedureDeviceActionCodes (preferred)Constraints
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manipulated | I | 1..1 | Reference(Device | HdBe MedicalDevice.Product) | Element IdProcedure.focalDevice.manipulated MedicalDevice Alternate namesMedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Device | HdBe MedicalDevice.Product) Constraints
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usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element IdProcedure.usedReference Items used during procedure DefinitionIdentifies medications, devices and any other substance used as part of the procedure. Used for tracking contamination, etc. For devices actually implanted or removed, use Procedure.device. Reference(Device | Medication | Substance) Constraints
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usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.usedCode Coded items used during the procedure DefinitionIdentifies coded items that were used as part of the procedure. For devices actually implanted or removed, use Procedure.device. Codes describing items used during a procedure. FHIRDeviceTypes (example)Constraints
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Procedure | I | Procedure | Element IdProcedure Procedure Alternate namesVerrichting DefinitionAn 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. The CBB Procedure is mapped both to a Procedure profile and a profile on ServiceRequest to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings, with the exception of the Requester concept; this is not relevant for past procedures and has only been mapped to the ServiceRequest profile. The planned and performed procedures can be linked using
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extension | I | 0..* | Extension | Element IdProcedure.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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procedureMethod | I | 0..* | Extension(CodeableConcept) | Element IdProcedure.extension:procedureMethod The method used to perform the procedure Alternate namesextensions, user content DefinitionThe method used to perform this procedure. 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. https://fhir.healthdata.be/StructureDefinition/ext-Procedure.ProcedureMethod Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdProcedure.identifier External Identifiers for this procedure DefinitionBusiness 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. Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. 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.
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instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | There are no (further) constraints on this element Element IdProcedure.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe 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. canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Constraints
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instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdProcedure.instantiatesUri Instantiates external protocol or definition DefinitionThe 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. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | HdBe Procedure request) | Element IdProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. The root element provides more information on the usage of Reference(CarePlan | ServiceRequest | HdBe Procedure request) Constraints
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partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element IdProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. 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). Reference(Procedure | Observation | MedicationAdministration) Constraints
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status | Σ ?! | 1..1 | codeBinding | Element IdProcedure.status preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown DefinitionThis element is implictly mapped to the concepts ProcedureStartDate and ProcedureEndDate. Unless the status is explicitly recorded, the following guidance applies:
The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the procedure. EventStatus (required)Constraints
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statusReason | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.statusReason Reason for current status Alternate namesSuspended Reason, Cancelled Reason DefinitionCaptures the reason for the current state of the procedure. 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. A code that identifies the reason a procedure was not performed. ProcedureNotPerformedReason(SNOMED-CT) (example)Constraints
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category | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that classifies a procedure for searching, sorting and display purposes. ProcedureCategoryCodes(SNOMEDCT) (example)Constraints
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code | Σ | 0..1 | CodeableConceptBinding | Element IdProcedure.code ProcedureType Alternate namestype, VerrichtingType DefinitionThe name of the procedure. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code to identify a specific procedure . ProcedureType (extensible)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdProcedure.encounter Encounter created as part of DefinitionThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. 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.
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performed[x] | Σ | 0..1 | Element IdProcedure.performed[x] When the procedure was performed DefinitionEstimated 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. 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. Unordered, Open, by $this(Type) Constraints
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performedString | string | There are no (further) constraints on this element Data Type | ||
performedAge | Age | There are no (further) constraints on this element Data Type | ||
performedRange | Range | There are no (further) constraints on this element Data Type | ||
performedPeriod | Σ | 0..1 | Period | Element IdProcedure.performed[x]:performedPeriod When the procedure was performed DefinitionEstimated 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. 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.
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start | Σ I | 0..1 | dateTime | Element IdProcedure.performed[x]:performedPeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | Element IdProcedure.performed[x]:performedPeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
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performedDateTime | Σ | 0..1 | dateTime | Element IdProcedure.performed[x]:performedDateTime ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. 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.
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recorder | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdProcedure.recorder Who recorded the procedure DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints
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asserter | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdProcedure.asserter Person who asserts this procedure DefinitionIndividual who is making the procedure statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints
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performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdProcedure.performer The people who performed the procedure DefinitionLimited to "real" people rather than equipment.
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function | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.performer.function Type of performance DefinitionDistinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Allows disambiguation of the types of involvement of different performers. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the role of a performer of the procedure. ProcedurePerformerRoleCodes (example)Constraints
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actor | Σ I | 1..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdProcedure.performer.actor Performer Alternate namesUitvoerder DefinitionThe health professional who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. A reference to Device supports use cases, such as pacemakers. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
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onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdProcedure.performer.onBehalfOf Organization the device or practitioner was acting for DefinitionThe organization the device or practitioner was acting on behalf of. Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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location | Σ I | 0..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdProcedure.location Location Alternate namesLocatie DefinitionThe healthcare provider where the procedure was, is or or will be carried out. Ties a procedure to where the records are likely kept. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | HdBe HealthcareOrganization) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.reasonCode Coded reason procedure performed DefinitionThe coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. 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. A code that identifies the reason a procedure is required. ProcedureReasonCodes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference | HdBe Problem) | Element IdProcedure.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. 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. Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference | HdBe Problem) Constraints
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bodySite | Σ | 0..1 | HdBe AnatomicalLocationBinding | Element IdProcedure.bodySite Location / ProcedureAnatomicalLocation Alternate namesLocatie, VerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. Location (required)Constraints
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outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.outcome The result of procedure DefinitionThe outcome of the procedure - did it resolve the reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text. An outcome of a procedure - whether it was resolved or otherwise. ProcedureOutcomeCodes(SNOMEDCT) (example)Constraints
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report | I | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Element IdProcedure.report Any report resulting from the procedure DefinitionThis could be a histology result, pathology report, surgical report, etc. 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. Reference(DiagnosticReport | DocumentReference | Composition) Sliced:Unordered, Open, by resolve()(Profile) Constraints
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textResult | I | 0..* | Reference(https://fhir.healthdata.be/StructureDefinition/HdBe-TextResult) | Element IdProcedure.report:textResult TextResult Alternate namesTekstUitslag DefinitionThis could be a histology result, pathology report, surgical report, etc. The direction of the reference between CBBs TextResult and Procedure is reversed in FHIR. Therefore the concept Procedure of zib TextResult is mapped to this element. Please note that on a functional level, TextResult references Procedure, but in FHIR this direction is reversed. Reference(https://fhir.healthdata.be/StructureDefinition/HdBe-TextResult) Constraints
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complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.complication Complication following the procedure DefinitionAny 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. If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Codes describing complications that resulted from a procedure. Condition/Problem/DiagnosisCodes (example)Constraints
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complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element IdProcedure.complicationDetail A condition that is a result of the procedure DefinitionAny complications that occurred during the procedure, or in the immediate post-performance period. This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.followUp Instructions for follow up DefinitionIf 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Specific follow up required for a procedure e.g. removal of sutures. ProcedureFollowUpCodes(SNOMEDCT) (example)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdProcedure.note Additional information about the procedure DefinitionAny other notes and comments about the procedure. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element IdProcedure.focalDevice Manipulated, implanted, or removed device DefinitionA 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.
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action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdProcedure.focalDevice.action Kind of change to device DefinitionThe kind of change that happened to the device during the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A kind of change that happened to the device during the procedure. ProcedureDeviceActionCodes (preferred)Constraints
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manipulated | I | 1..1 | Reference(Device | HdBe MedicalDevice.Product) | Element IdProcedure.focalDevice.manipulated MedicalDevice Alternate namesMedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Device | HdBe MedicalDevice.Product) Constraints
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usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element IdProcedure.usedReference Items used during procedure DefinitionIdentifies medications, devices and any other substance used as part of the procedure. Used for tracking contamination, etc. For devices actually implanted or removed, use Procedure.device. Reference(Device | Medication | Substance) Constraints
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usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.usedCode Coded items used during the procedure DefinitionIdentifies coded items that were used as part of the procedure. For devices actually implanted or removed, use Procedure.device. Codes describing items used during a procedure. FHIRDeviceTypes (example)Constraints
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Procedure | I | Procedure | Element IdProcedure Procedure Alternate namesVerrichting DefinitionAn 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. The CBB Procedure is mapped both to a Procedure profile and a profile on ServiceRequest to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings, with the exception of the Requester concept; this is not relevant for past procedures and has only been mapped to the ServiceRequest profile. The planned and performed procedures can be linked using
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extension | I | 0..* | Extension | Element IdProcedure.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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procedureMethod | I | 0..* | Extension(CodeableConcept) | Element IdProcedure.extension:procedureMethod The method used to perform the procedure Alternate namesextensions, user content DefinitionThe method used to perform this procedure. 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. https://fhir.healthdata.be/StructureDefinition/ext-Procedure.ProcedureMethod Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdProcedure.identifier External Identifiers for this procedure DefinitionBusiness 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. Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. 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.
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instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | There are no (further) constraints on this element Element IdProcedure.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe 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. canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Constraints
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instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdProcedure.instantiatesUri Instantiates external protocol or definition DefinitionThe 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. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | HdBe Procedure request) | Element IdProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. The root element provides more information on the usage of Reference(CarePlan | ServiceRequest | HdBe Procedure request) Constraints
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partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element IdProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. 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). Reference(Procedure | Observation | MedicationAdministration) Constraints
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status | Σ ?! | 1..1 | codeBinding | Element IdProcedure.status preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown DefinitionThis element is implictly mapped to the concepts ProcedureStartDate and ProcedureEndDate. Unless the status is explicitly recorded, the following guidance applies:
The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the procedure. EventStatus (required)Constraints
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statusReason | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.statusReason Reason for current status Alternate namesSuspended Reason, Cancelled Reason DefinitionCaptures the reason for the current state of the procedure. 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. A code that identifies the reason a procedure was not performed. ProcedureNotPerformedReason(SNOMED-CT) (example)Constraints
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category | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.category Classification of the procedure DefinitionA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that classifies a procedure for searching, sorting and display purposes. ProcedureCategoryCodes(SNOMEDCT) (example)Constraints
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code | Σ | 0..1 | CodeableConceptBinding | Element IdProcedure.code ProcedureType Alternate namestype, VerrichtingType DefinitionThe name of the procedure. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code to identify a specific procedure . ProcedureType (extensible)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdProcedure.encounter Encounter created as part of DefinitionThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. 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.
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performed[x] | Σ | 0..1 | Element IdProcedure.performed[x] When the procedure was performed DefinitionEstimated 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. 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. Unordered, Open, by $this(Type) Constraints
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performedString | string | There are no (further) constraints on this element Data Type | ||
performedAge | Age | There are no (further) constraints on this element Data Type | ||
performedRange | Range | There are no (further) constraints on this element Data Type | ||
performedPeriod | Σ | 0..1 | Period | Element IdProcedure.performed[x]:performedPeriod When the procedure was performed DefinitionEstimated 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. 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.
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start | Σ I | 0..1 | dateTime | Element IdProcedure.performed[x]:performedPeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | Element IdProcedure.performed[x]:performedPeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
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performedDateTime | Σ | 0..1 | dateTime | Element IdProcedure.performed[x]:performedDateTime ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. 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.
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recorder | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdProcedure.recorder Who recorded the procedure DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints
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asserter | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element IdProcedure.asserter Person who asserts this procedure DefinitionIndividual who is making the procedure statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints
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performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdProcedure.performer The people who performed the procedure DefinitionLimited to "real" people rather than equipment.
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function | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.performer.function Type of performance DefinitionDistinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Allows disambiguation of the types of involvement of different performers. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A code that identifies the role of a performer of the procedure. ProcedurePerformerRoleCodes (example)Constraints
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actor | Σ I | 1..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdProcedure.performer.actor Performer Alternate namesUitvoerder DefinitionThe health professional who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. A reference to Device supports use cases, such as pacemakers. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
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onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdProcedure.performer.onBehalfOf Organization the device or practitioner was acting for DefinitionThe organization the device or practitioner was acting on behalf of. Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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location | Σ I | 0..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdProcedure.location Location Alternate namesLocatie DefinitionThe healthcare provider where the procedure was, is or or will be carried out. Ties a procedure to where the records are likely kept. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | HdBe HealthcareOrganization) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.reasonCode Coded reason procedure performed DefinitionThe coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. 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. A code that identifies the reason a procedure is required. ProcedureReasonCodes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference | HdBe Problem) | Element IdProcedure.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. 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. Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference | HdBe Problem) Constraints
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bodySite | Σ | 0..1 | HdBe AnatomicalLocationBinding | Element IdProcedure.bodySite Location / ProcedureAnatomicalLocation Alternate namesLocatie, VerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. Location (required)Constraints
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outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.outcome The result of procedure DefinitionThe outcome of the procedure - did it resolve the reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text. An outcome of a procedure - whether it was resolved or otherwise. ProcedureOutcomeCodes(SNOMEDCT) (example)Constraints
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report | I | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Element IdProcedure.report Any report resulting from the procedure DefinitionThis could be a histology result, pathology report, surgical report, etc. 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. Reference(DiagnosticReport | DocumentReference | Composition) Sliced:Unordered, Open, by resolve()(Profile) Constraints
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textResult | I | 0..* | Reference(https://fhir.healthdata.be/StructureDefinition/HdBe-TextResult) | Element IdProcedure.report:textResult TextResult Alternate namesTekstUitslag DefinitionThis could be a histology result, pathology report, surgical report, etc. The direction of the reference between CBBs TextResult and Procedure is reversed in FHIR. Therefore the concept Procedure of zib TextResult is mapped to this element. Please note that on a functional level, TextResult references Procedure, but in FHIR this direction is reversed. Reference(https://fhir.healthdata.be/StructureDefinition/HdBe-TextResult) Constraints
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complication | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.complication Complication following the procedure DefinitionAny 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. If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Codes describing complications that resulted from a procedure. Condition/Problem/DiagnosisCodes (example)Constraints
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complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element IdProcedure.complicationDetail A condition that is a result of the procedure DefinitionAny complications that occurred during the procedure, or in the immediate post-performance period. This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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followUp | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.followUp Instructions for follow up DefinitionIf 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. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Specific follow up required for a procedure e.g. removal of sutures. ProcedureFollowUpCodes(SNOMEDCT) (example)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdProcedure.note Additional information about the procedure DefinitionAny other notes and comments about the procedure. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element IdProcedure.focalDevice Manipulated, implanted, or removed device DefinitionA 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.
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action | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdProcedure.focalDevice.action Kind of change to device DefinitionThe kind of change that happened to the device during the procedure. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A kind of change that happened to the device during the procedure. ProcedureDeviceActionCodes (preferred)Constraints
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manipulated | I | 1..1 | Reference(Device | HdBe MedicalDevice.Product) | Element IdProcedure.focalDevice.manipulated MedicalDevice Alternate namesMedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Device | HdBe MedicalDevice.Product) Constraints
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usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element IdProcedure.usedReference Items used during procedure DefinitionIdentifies medications, devices and any other substance used as part of the procedure. Used for tracking contamination, etc. For devices actually implanted or removed, use Procedure.device. Reference(Device | Medication | Substance) Constraints
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usedCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdProcedure.usedCode Coded items used during the procedure DefinitionIdentifies coded items that were used as part of the procedure. For devices actually implanted or removed, use Procedure.device. Codes describing items used during a procedure. FHIRDeviceTypes (example)Constraints
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Mapping FHIR profile to CBB
Path | map | CBB |
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Procedure | Procedure | HdBe-Procedure |
Procedure.extension:procedureMethod | ProcedureMethod | HdBe-Procedure |
Procedure.status | ProcedureStartDate (implicit, main mapping is on Procedure.PerformedPeriod.Start and Procedure.PerformedDateTime) | HdBe-Procedure |
Procedure.status | ProcedureEndDate (implicit, main mapping is on Procedure.PerformedPeriod.End) | HdBe-Procedure |
Procedure.code | ProcedureType | HdBe-Procedure |
Procedure.performed[x]:performedPeriod.start | ProcedureStartDate | HdBe-Procedure |
Procedure.performed[x]:performedPeriod.end | ProcedureEndDate | HdBe-Procedure |
Procedure.performed[x]:performedDateTime | ProcedureStartDate | HdBe-Procedure |
Procedure.performer.actor | Performer | HdBe-Procedure |
Procedure.location | Location | HdBe-Procedure |
Procedure.reasonReference | Indication | HdBe-Procedure |
Procedure.bodySite | ProcedureAnatomicalLocation | HdBe-Procedure |
Procedure.focalDevice.manipulated | MedicalDevice | HdBe-Procedure |
zib Procedure-event difference
Concept | Category | Description | |
---|---|---|---|
code |
terminology | Replaced (Dutch) ValueSets with one ValueSet that includes all SNOMED child concepts of 71388002 | Procedure (procedure) and made it extensible. |
code |
textual | Removed mentioning of Dutch ValueSets in the definition. | |
location |
textual | Replaced 'healthcare center' with 'healthcare provider' in the definition. | |
performer.actor |
textual | Replaced 'healthcare provider' with 'healthcare professional' in the definition. | |
extension:procedureMethod |
terminology | Widened terminology from descendent of 129264002 | Action to all of SNOMED. Changed the binding from required to extensible. |
HdBe-Procedure-request
ServiceRequest | I | ServiceRequest | Element IdServiceRequest Procedure Alternate namesdiagnostic request, referral, referral request, transfer of care request, Verrichting DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed. The CBB Procedure is mapped both to this ServiceRequest profile and a profile on Procedure (https://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-event) to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings. The planned and performed procedures can be linked using
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdServiceRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
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instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element IdServiceRequest.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Note: 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 a Person resource instance might share the same social insurance number. canonical(ActivityDefinition | PlanDefinition) Constraints
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instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdServiceRequest.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | MedicationRequest) | There are no (further) constraints on this element Element IdServiceRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(CarePlan | ServiceRequest | MedicationRequest) Constraints
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replaces | Σ I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdServiceRequest.replaces What request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdServiceRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
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status | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionThis element is implictly mapped to the concepts ProcedureStartDate (NL-CM:14.1.2) and ProcedureEndDate (NL-CM:14.1.3). Unless the status is explicitly recorded, the following guidance applies:
The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. The status of a service order. RequestStatus (required)Constraints
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intent | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.intent proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option DefinitionUnless intent is explicitly recorded and a more appropriate code is known, the value can be set to order because a Procedure should authorize an action for a patient, pharmacist, professional administrator et cetera. This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. The kind of service request. RequestIntent (required)Constraints
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.category Classification of service DefinitionA code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what service request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the requested service. ServiceRequestCategoryCodes (example)Constraints
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priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdServiceRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests. Note that FHIR strings SHALL NOT exceed 1MB in size Identifies the level of importance to be assigned to actioning the request. RequestPriority (required)Constraints
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doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element IdServiceRequest.doNotPerform True if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
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code | Σ | 0..1 | CodeableConceptBinding | Element IdServiceRequest.code ProcedureType Alternate namesservice requested, VerrichtingType DefinitionThe name of the procedure. Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureType (extensible)Constraints
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orderDetail | Σ I | 0..* | CodeableConcept | Element IdServiceRequest.orderDetail Additional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. For information from the medical record intended to support the delivery of the requested services, use the Unordered, Open, by $this(Value) BindingCodified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example)Constraints
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procedureMethod | Σ I | 0..* | CodeableConceptBinding | Element IdServiceRequest.orderDetail:procedureMethod ProcedureMethod Alternate namesdetailed instructions, VerrichtingMethode DefinitionThe method or technique that will be used to perform the procedure, e.g. approach, lavage, pressuring, ets. For information from the medical record intended to support the delivery of the requested services, use the Codified order entry details which are based on order context. ProcedureMethod (required)Constraints
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quantity[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.quantity[x] Service amount DefinitionAn amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). When ordering a service the number of service items may need to be specified separately from the the service item.
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quantityQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
quantityRatio | Ratio | There are no (further) constraints on this element Data Type | ||
quantityRange | Range | There are no (further) constraints on this element Data Type | ||
subject | Σ I | 1..1 | Reference(Patient | Group | Location | Device) | There are no (further) constraints on this element Element IdServiceRequest.subject Individual or Entity the service is ordered for DefinitionOn whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Group | Location | Device) Constraints
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdServiceRequest.encounter Encounter in which the request was created Alternate namescontext DefinitionAn encounter that provides additional information about the healthcare context in which this request is made. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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occurrence[x] | Σ | 0..1 | Element IdServiceRequest.occurrence[x] ProcedureStartDate / ProcedureEndDate Alternate namesschedule, VerrichtingStartDatum, VerrichtingEindDatum Definition
The Unordered, Open, by $this(Type) Constraints
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occurrenceTiming | Timing | There are no (further) constraints on this element Data Type | ||
occurrencePeriod | Σ | 0..1 | Period | Element IdServiceRequest.occurrence[x]:occurrencePeriod When service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
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start | Σ I | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrencePeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrencePeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
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occurrenceDateTime | Σ | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrenceDateTime ProcedureStartDate Alternate namesschedule, VerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures.
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asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.asNeeded[x] Preconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example)Constraints
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asNeededBoolean | boolean | There are no (further) constraints on this element Data Type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdServiceRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
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requester | Σ I | 0..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdServiceRequest.requester Requester Alternate namesauthor, orderer, Aanvrager DefinitionThe health professional who requested the procedure. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
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performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.performerType Performer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service. This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example)Constraints
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performer | Σ I | 0..* | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson | HdBe HealthProfessional PractitionerRole | https://fhir.healthdata.be/StructureDefinition/HdBe-CareTeam) | Element IdServiceRequest.performer Performer Alternate namesrequest recipient, Uitvoerder DefinitionThe healthcare provider who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. This deviates from the CBB definition where multiple references to the Healthprofessional should be interperted as all the performers of the procedure. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson | HdBe HealthProfessional PractitionerRole | https://fhir.healthdata.be/StructureDefinition/HdBe-CareTeam) Constraints
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locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.locationCode Requested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example)Constraints
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locationReference | Σ I | 0..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdServiceRequest.locationReference Location Alternate namesLocatie DefinitionThe healthcare provider where the procedure was, is or or will be carried out. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | HdBe HealthcareOrganization) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.reasonCode Explanation/Justification for procedure or service DefinitionAn explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference | HdBe Problem) | Element IdServiceRequest.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in Reference(Condition | Observation | DiagnosticReport | DocumentReference | HdBe Problem) Constraints
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insurance | I | 0..* | Reference(Coverage | ClaimResponse) | There are no (further) constraints on this element Element IdServiceRequest.insurance Associated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Coverage | ClaimResponse) Constraints
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supportingInfo | I | 0..* | Reference(Resource | HdBe MedicalDevice) | Element IdServiceRequest.supportingInfo MedicalDevice Alternate namesAsk at order entry question, AOE, MedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. To represent information about how the services are to be delivered use the Reference(Resource | HdBe MedicalDevice) Constraints
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specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdServiceRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
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bodySite | Σ | 0..1 | HdBe AnatomicalLocationBinding | Element IdServiceRequest.bodySite Location / ProcedureAnatomicalLocation Alternate nameslocation, Locatie, VerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of the procedure. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. Location (required)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdServiceRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, internal billing notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element IdServiceRequest.patientInstruction Patient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings SHALL NOT exceed 1MB in size
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relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element IdServiceRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
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ServiceRequest | I | ServiceRequest | Element IdServiceRequest Procedure Alternate namesdiagnostic request, referral, referral request, transfer of care request, Verrichting DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed. The CBB Procedure is mapped both to this ServiceRequest profile and a profile on Procedure (https://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-event) to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings. The planned and performed procedures can be linked using
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdServiceRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
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instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element IdServiceRequest.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Note: 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 a Person resource instance might share the same social insurance number. canonical(ActivityDefinition | PlanDefinition) Constraints
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instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdServiceRequest.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | MedicationRequest) | There are no (further) constraints on this element Element IdServiceRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(CarePlan | ServiceRequest | MedicationRequest) Constraints
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replaces | Σ I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdServiceRequest.replaces What request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdServiceRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
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status | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionThis element is implictly mapped to the concepts ProcedureStartDate (NL-CM:14.1.2) and ProcedureEndDate (NL-CM:14.1.3). Unless the status is explicitly recorded, the following guidance applies:
The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. The status of a service order. RequestStatus (required)Constraints
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intent | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.intent proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option DefinitionUnless intent is explicitly recorded and a more appropriate code is known, the value can be set to order because a Procedure should authorize an action for a patient, pharmacist, professional administrator et cetera. This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. The kind of service request. RequestIntent (required)Constraints
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.category Classification of service DefinitionA code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what service request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the requested service. ServiceRequestCategoryCodes (example)Constraints
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priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdServiceRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests. Note that FHIR strings SHALL NOT exceed 1MB in size Identifies the level of importance to be assigned to actioning the request. RequestPriority (required)Constraints
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doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element IdServiceRequest.doNotPerform True if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
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code | Σ | 0..1 | CodeableConceptBinding | Element IdServiceRequest.code ProcedureType Alternate namesservice requested, VerrichtingType DefinitionThe name of the procedure. Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureType (extensible)Constraints
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orderDetail | Σ I | 0..* | CodeableConcept | Element IdServiceRequest.orderDetail Additional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. For information from the medical record intended to support the delivery of the requested services, use the Unordered, Open, by $this(Value) BindingCodified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example)Constraints
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procedureMethod | Σ I | 0..* | CodeableConceptBinding | Element IdServiceRequest.orderDetail:procedureMethod ProcedureMethod Alternate namesdetailed instructions, VerrichtingMethode DefinitionThe method or technique that will be used to perform the procedure, e.g. approach, lavage, pressuring, ets. For information from the medical record intended to support the delivery of the requested services, use the Codified order entry details which are based on order context. ProcedureMethod (required)Constraints
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quantity[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.quantity[x] Service amount DefinitionAn amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). When ordering a service the number of service items may need to be specified separately from the the service item.
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quantityQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
quantityRatio | Ratio | There are no (further) constraints on this element Data Type | ||
quantityRange | Range | There are no (further) constraints on this element Data Type | ||
subject | Σ I | 1..1 | Reference(Patient | Group | Location | Device) | There are no (further) constraints on this element Element IdServiceRequest.subject Individual or Entity the service is ordered for DefinitionOn whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Group | Location | Device) Constraints
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdServiceRequest.encounter Encounter in which the request was created Alternate namescontext DefinitionAn encounter that provides additional information about the healthcare context in which this request is made. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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occurrence[x] | Σ | 0..1 | Element IdServiceRequest.occurrence[x] ProcedureStartDate / ProcedureEndDate Alternate namesschedule, VerrichtingStartDatum, VerrichtingEindDatum Definition
The Unordered, Open, by $this(Type) Constraints
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occurrenceTiming | Timing | There are no (further) constraints on this element Data Type | ||
occurrencePeriod | Σ | 0..1 | Period | Element IdServiceRequest.occurrence[x]:occurrencePeriod When service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
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start | Σ I | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrencePeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrencePeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
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occurrenceDateTime | Σ | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrenceDateTime ProcedureStartDate Alternate namesschedule, VerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures.
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asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.asNeeded[x] Preconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example)Constraints
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asNeededBoolean | boolean | There are no (further) constraints on this element Data Type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdServiceRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
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requester | Σ I | 0..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdServiceRequest.requester Requester Alternate namesauthor, orderer, Aanvrager DefinitionThe health professional who requested the procedure. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
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performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.performerType Performer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service. This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example)Constraints
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performer | Σ I | 0..* | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson | HdBe HealthProfessional PractitionerRole | https://fhir.healthdata.be/StructureDefinition/HdBe-CareTeam) | Element IdServiceRequest.performer Performer Alternate namesrequest recipient, Uitvoerder DefinitionThe healthcare provider who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. This deviates from the CBB definition where multiple references to the Healthprofessional should be interperted as all the performers of the procedure. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson | HdBe HealthProfessional PractitionerRole | https://fhir.healthdata.be/StructureDefinition/HdBe-CareTeam) Constraints
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locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.locationCode Requested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example)Constraints
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locationReference | Σ I | 0..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdServiceRequest.locationReference Location Alternate namesLocatie DefinitionThe healthcare provider where the procedure was, is or or will be carried out. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | HdBe HealthcareOrganization) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.reasonCode Explanation/Justification for procedure or service DefinitionAn explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference | HdBe Problem) | Element IdServiceRequest.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in Reference(Condition | Observation | DiagnosticReport | DocumentReference | HdBe Problem) Constraints
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insurance | I | 0..* | Reference(Coverage | ClaimResponse) | There are no (further) constraints on this element Element IdServiceRequest.insurance Associated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Coverage | ClaimResponse) Constraints
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supportingInfo | I | 0..* | Reference(Resource | HdBe MedicalDevice) | Element IdServiceRequest.supportingInfo MedicalDevice Alternate namesAsk at order entry question, AOE, MedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. To represent information about how the services are to be delivered use the Reference(Resource | HdBe MedicalDevice) Constraints
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specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdServiceRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
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bodySite | Σ | 0..1 | HdBe AnatomicalLocationBinding | Element IdServiceRequest.bodySite Location / ProcedureAnatomicalLocation Alternate nameslocation, Locatie, VerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of the procedure. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. Location (required)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdServiceRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, internal billing notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element IdServiceRequest.patientInstruction Patient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings SHALL NOT exceed 1MB in size
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relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element IdServiceRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
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ServiceRequest | I | ServiceRequest | Element IdServiceRequest Procedure Alternate namesdiagnostic request, referral, referral request, transfer of care request, Verrichting DefinitionA record of a request for service such as diagnostic investigations, treatments, or operations to be performed. The CBB Procedure is mapped both to this ServiceRequest profile and a profile on Procedure (https://fhir.healthdata.be/StructureDefinition/HdBe-Procedure-event) to align with the intention of FHIR. All past procedures are covered using this Procedure resource, while all future procedures, including the advised procedures, are covered in the ServiceRequest resource. Both resources contain the CBB mappings. The planned and performed procedures can be linked using
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdServiceRequest.identifier Identifiers assigned to this order DefinitionIdentifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below.
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instantiatesCanonical | Σ | 0..* | canonical(ActivityDefinition | PlanDefinition) | There are no (further) constraints on this element Element IdServiceRequest.instantiatesCanonical Instantiates FHIR protocol or definition DefinitionThe URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Note: 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 a Person resource instance might share the same social insurance number. canonical(ActivityDefinition | PlanDefinition) Constraints
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instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element IdServiceRequest.instantiatesUri Instantiates external protocol or definition DefinitionThe URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
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basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest | MedicationRequest) | There are no (further) constraints on this element Element IdServiceRequest.basedOn What request fulfills Alternate namesfulfills DefinitionPlan/proposal/order fulfilled by this request. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(CarePlan | ServiceRequest | MedicationRequest) Constraints
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replaces | Σ I | 0..* | Reference(ServiceRequest) | There are no (further) constraints on this element Element IdServiceRequest.replaces What request replaces Alternate namessupersedes, prior, renewed order DefinitionThe request takes the place of the referenced completed or terminated request(s). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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requisition | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdServiceRequest.requisition Composite Request ID Alternate namesgrouperId, groupIdentifier DefinitionA shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation.
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status | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.status draft | active | on-hold | revoked | completed | entered-in-error | unknown DefinitionThis element is implictly mapped to the concepts ProcedureStartDate (NL-CM:14.1.2) and ProcedureEndDate (NL-CM:14.1.3). Unless the status is explicitly recorded, the following guidance applies:
The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. The status of a service order. RequestStatus (required)Constraints
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intent | Σ ?! | 1..1 | codeBinding | Element IdServiceRequest.intent proposal | plan | directive | order | original-order | reflex-order | filler-order | instance-order | option DefinitionUnless intent is explicitly recorded and a more appropriate code is known, the value can be set to order because a Procedure should authorize an action for a patient, pharmacist, professional administrator et cetera. This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. The kind of service request. RequestIntent (required)Constraints
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category | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.category Classification of service DefinitionA code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Used for filtering what service request are retrieved and displayed. There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Classification of the requested service. ServiceRequestCategoryCodes (example)Constraints
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priority | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdServiceRequest.priority routine | urgent | asap | stat DefinitionIndicates how quickly the ServiceRequest should be addressed with respect to other requests. Note that FHIR strings SHALL NOT exceed 1MB in size Identifies the level of importance to be assigned to actioning the request. RequestPriority (required)Constraints
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doNotPerform | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element IdServiceRequest.doNotPerform True if service/procedure should not be performed DefinitionSet this to true if the record is saying that the service/procedure should NOT be performed. Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation.
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code | Σ | 0..1 | CodeableConceptBinding | Element IdServiceRequest.code ProcedureType Alternate namesservice requested, VerrichtingType DefinitionThe name of the procedure. Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureType (extensible)Constraints
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orderDetail | Σ I | 0..* | CodeableConcept | Element IdServiceRequest.orderDetail Additional order information Alternate namesdetailed instructions DefinitionAdditional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. For information from the medical record intended to support the delivery of the requested services, use the Unordered, Open, by $this(Value) BindingCodified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example)Constraints
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procedureMethod | Σ I | 0..* | CodeableConceptBinding | Element IdServiceRequest.orderDetail:procedureMethod ProcedureMethod Alternate namesdetailed instructions, VerrichtingMethode DefinitionThe method or technique that will be used to perform the procedure, e.g. approach, lavage, pressuring, ets. For information from the medical record intended to support the delivery of the requested services, use the Codified order entry details which are based on order context. ProcedureMethod (required)Constraints
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quantity[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.quantity[x] Service amount DefinitionAn amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). When ordering a service the number of service items may need to be specified separately from the the service item.
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quantityQuantity | Quantity | There are no (further) constraints on this element Data Type | ||
quantityRatio | Ratio | There are no (further) constraints on this element Data Type | ||
quantityRange | Range | There are no (further) constraints on this element Data Type | ||
subject | Σ I | 1..1 | Reference(Patient | Group | Location | Device) | There are no (further) constraints on this element Element IdServiceRequest.subject Individual or Entity the service is ordered for DefinitionOn whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Group | Location | Device) Constraints
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdServiceRequest.encounter Encounter in which the request was created Alternate namescontext DefinitionAn encounter that provides additional information about the healthcare context in which this request is made. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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occurrence[x] | Σ | 0..1 | Element IdServiceRequest.occurrence[x] ProcedureStartDate / ProcedureEndDate Alternate namesschedule, VerrichtingStartDatum, VerrichtingEindDatum Definition
The Unordered, Open, by $this(Type) Constraints
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occurrenceTiming | Timing | There are no (further) constraints on this element Data Type | ||
occurrencePeriod | Σ | 0..1 | Period | Element IdServiceRequest.occurrence[x]:occurrencePeriod When service should occur Alternate namesschedule DefinitionThe date/time at which the requested service should occur.
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start | Σ I | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrencePeriod.start ProcedureStartDate Alternate namesVerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures. If the low element is missing, the meaning is that the low boundary is not known.
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end | Σ I | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrencePeriod.end ProcedureEndDate Alternate namesVerrichtingEindDatum DefinitionThe end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
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occurrenceDateTime | Σ | 0..1 | dateTime | Element IdServiceRequest.occurrence[x]:occurrenceDateTime ProcedureStartDate Alternate namesschedule, VerrichtingStartDatum DefinitionThe (desired) start date (and if possible start time) of the procedure. A ‘vague’ date, such as only the year, is permitted. The element offers the option to indicate the start of the period of a series of related procedures.
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asNeeded[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdServiceRequest.asNeeded[x] Preconditions for service DefinitionIf a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example)Constraints
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asNeededBoolean | boolean | There are no (further) constraints on this element Data Type | ||
asNeededCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data Type | ||
authoredOn | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdServiceRequest.authoredOn Date request signed Alternate namesorderedOn DefinitionWhen the request transitioned to being actionable.
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requester | Σ I | 0..1 | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) | Element IdServiceRequest.requester Requester Alternate namesauthor, orderer, Aanvrager DefinitionThe health professional who requested the procedure. Each occurrence of the CBB HealthProfessional is normally represented by two FHIR resources: a PractitionerRole resource (instance of HdBe-HealthProfessional-PractitionerRole) and a Practitioner resource (instance of HdBe-HealthProfessional-Practitioner). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance. In rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the HdBe-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile. pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device | HdBe HealthProfessional PractitionerRole) Constraints
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performerType | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.performerType Performer role Alternate namesspecialty DefinitionDesired type of performer for doing the requested service. This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example)Constraints
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performer | Σ I | 0..* | pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson | HdBe HealthProfessional PractitionerRole | https://fhir.healthdata.be/StructureDefinition/HdBe-CareTeam) | Element IdServiceRequest.performer Performer Alternate namesrequest recipient, Uitvoerder DefinitionThe healthcare provider who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the healthcare provider. If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. This deviates from the CBB definition where multiple references to the Healthprofessional should be interperted as all the performers of the procedure. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). pattern HealthProfessional Reference(Practitioner | PractitionerRole | Organization | CareTeam | HealthcareService | Patient | Device | RelatedPerson | HdBe HealthProfessional PractitionerRole | https://fhir.healthdata.be/StructureDefinition/HdBe-CareTeam) Constraints
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locationCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.locationCode Requested location DefinitionThe preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example)Constraints
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locationReference | Σ I | 0..1 | Reference(Location | HdBe HealthcareOrganization) | Element IdServiceRequest.locationReference Location Alternate namesLocatie DefinitionThe healthcare provider where the procedure was, is or or will be carried out. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Location | HdBe HealthcareOrganization) Constraints
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reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdServiceRequest.reasonCode Explanation/Justification for procedure or service DefinitionAn explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example)Constraints
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reasonReference | Σ I | 0..* | Reference(Condition | Observation | DiagnosticReport | DocumentReference | HdBe Problem) | Element IdServiceRequest.reasonReference Indication Alternate namesIndicatie DefinitionThe indication is the reason for the procedure. This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in Reference(Condition | Observation | DiagnosticReport | DocumentReference | HdBe Problem) Constraints
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insurance | I | 0..* | Reference(Coverage | ClaimResponse) | There are no (further) constraints on this element Element IdServiceRequest.insurance Associated insurance coverage DefinitionInsurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Coverage | ClaimResponse) Constraints
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supportingInfo | I | 0..* | Reference(Resource | HdBe MedicalDevice) | Element IdServiceRequest.supportingInfo MedicalDevice Alternate namesAsk at order entry question, AOE, MedischHulpmiddel DefinitionThe product, the placing of which in or on the body is the purpose of the procedure, for example placing an implant. To represent information about how the services are to be delivered use the Reference(Resource | HdBe MedicalDevice) Constraints
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specimen | Σ I | 0..* | Reference(Specimen) | There are no (further) constraints on this element Element IdServiceRequest.specimen Procedure Samples DefinitionOne or more specimens that the laboratory procedure will use. Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest.
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bodySite | Σ | 0..1 | HdBe AnatomicalLocationBinding | Element IdServiceRequest.bodySite Location / ProcedureAnatomicalLocation Alternate nameslocation, Locatie, VerrichtingAnatomischeLocatie DefinitionAnatomical location which is the focus of the procedure. Knowing where the procedure is performed is important for tracking if multiple sites are possible. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing anatomical locations. May include laterality. Location (required)Constraints
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdServiceRequest.note Comments DefinitionAny other notes and comments made about the service request. For example, internal billing notes. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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patientInstruction | Σ | 0..1 | string | There are no (further) constraints on this element Element IdServiceRequest.patientInstruction Patient or consumer-oriented instructions DefinitionInstructions in terms that are understood by the patient or consumer. Note that FHIR strings SHALL NOT exceed 1MB in size
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relevantHistory | I | 0..* | Reference(Provenance) | There are no (further) constraints on this element Element IdServiceRequest.relevantHistory Request provenance DefinitionKey events in the history of the request. This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.
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Mapping FHIR profile to CBB
Path | map | CBB |
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ServiceRequest | Procedure | HdBe-Procedure |
ServiceRequest.status | ProcedureStartDate (implicit, main mapping is on ServiceRequest.OccurencePeriod.Start and ServiceRequest.OccurenceDateTime) | HdBe-Procedure |
ServiceRequest.status | ProcedureEndDate (implicit, main mapping is on ServiceRequest.OccurencePeriod.End) | HdBe-Procedure |
ServiceRequest.code | ProcedureType | HdBe-Procedure |
ServiceRequest.orderDetail:procedureMethod | ProcedureMethod | HdBe-Procedure |
ServiceRequest.occurrence[x] | ProcedureStartDate | HdBe-Procedure |
ServiceRequest.occurrence[x] | ProcedureEndDate | HdBe-Procedure |
ServiceRequest.occurrence[x]:occurrencePeriod.start | ProcedureStartDate | HdBe-Procedure |
ServiceRequest.occurrence[x]:occurrencePeriod.end | ProcedureEndDate | HdBe-Procedure |
ServiceRequest.occurrence[x]:occurrenceDateTime | ProcedureStartDate | HdBe-Procedure |
ServiceRequest.requester | Requester | HdBe-Procedure |
ServiceRequest.performer | Performer | HdBe-Procedure |
ServiceRequest.locationReference | Location | HdBe-Procedure |
ServiceRequest.reasonReference | Indication | HdBe-Procedure |
ServiceRequest.supportingInfo | MedicalDevice | HdBe-Procedure |
ServiceRequest.bodySite | ProcedureAnatomicalLocation | HdBe-Procedure |
zib Procedure-request difference
Concept | Category | Description | |
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code |
terminology | Replaced (Dutch) ValueSets with one ValueSet that includes all SNOMED child concepts of 71388002 | Procedure (procedure) and made it extensible. |
code |
textual | Removed mentioning of Dutch ValueSets in the definition. | |
orderDetail:procedureMethod |
terminology | Widened terminology from descendent of 129264002 | Action to all of SNOMED. Changed the binding from required to extensible. |
locationReference |
textual | Replaced 'healthcare center' with 'healthcare provider' in the definition. | |
requester |
textual | Replaced 'healthcare provider' with 'healthcare professional' in the definition. | |
requester |
textual | Removed comment about the cardinality mismatch between FHIR and zib, because we already have fixed the cardinality of requester in our CBB. Therefore this comment was not relevant anymore. |
Terminology Bindings
Path | Name | Strength | URL | ConceptMap |
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Procedure.code | ProcedureType | extensible | https://fhir.healthdata.be/ValueSet/ProcedureType | No bound ConceptMap |
Procedure.bodySite | Location | required | https://fhir.healthdata.be/ValueSet/Location | No bound ConceptMap |
ServiceRequest.code | ProcedureType | extensible | https://fhir.healthdata.be/ValueSet/ProcedureType | No bound ConceptMap |
ServiceRequest.orderDetail | ProcedureMethod | required | https://fhir.healthdata.be/ValueSet/ProcedureMethod | No bound ConceptMap |
ServiceRequest.bodySite | Location | required | https://fhir.healthdata.be/ValueSet/Location | No bound ConceptMap |