An action that is or was performed on a patient.
| CareConnect-Procedure-1 (Procedure) | I | Procedure | There are no (further) constraints on this element Element idProcedure An action that is being or was performed on a patient DefinitionAn action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. |
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language. Common Languages (extensible) | |
| text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
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| extension | 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. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Mappings
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| anaestheticIssues | I | 0..1 | Extension(Reference(CareConnect-Condition-1), CodeableConcept) | Element idProcedure.extension:anaestheticIssues Details of any adverse reaction to any anaesthetic agents Alternate namesextensions, user content DefinitionDetails of any adverse reaction to any anaesthetic agents. 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. Extension(Reference(CareConnect-Condition-1), CodeableConcept) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-AnaestheticIssues-1 Constraints
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| modifierExtension | ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier External Identifiers for this procedure DefinitionThis records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). Need to allow connection to a wider workflow.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.identifier.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.identifier.use usual | official | temp | secondary (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . IdentifierUse (required)Mappings
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible)Mappings
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.identifier.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. General http://www.acme.com/identifiers/patient Mappings
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| value | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. General 123456 Mappings
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedure.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
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| assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Element idProcedure.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. Reference(CareConnect-Organization-1) Mappings
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| definition | Σ | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | There are no (further) constraints on this element Element idProcedure.definition Instantiates protocol or definition DefinitionA protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure. Reference(PlanDefinition | ActivityDefinition | HealthcareService) Mappings
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| basedOn | Σ | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. Reference(CarePlan | ProcedureRequest | ReferralRequest) Mappings
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| partOf | Σ | 0..* | Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) | Element idProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, the anesthesia related medicationAdministration is part of the procedure. For an IV medication administration, the procedure to insert the IV port is part of the medication administration. Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) Mappings
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.status preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally this will be in-progress or completed state. 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)Mappings
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| notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDone True if procedure was not performed as scheduled DefinitionSet this to true if the record is saying that the procedure was NOT performed. If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome. This element is labeled as a modifier because it indicates that a procedure didn't happen. false
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| notDoneReason | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReason Reason procedure was not performed DefinitionA code indicating why the procedure was not performed. A code that identifies the reason a procedure was not performed. Procedure Not Performed Reason (SNOMED-CT) (example)Mappings
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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"). A code that classifies a procedure for searching, sorting and display purposes. Procedure Category Codes (SNOMED CT) (example)Mappings
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| code | Σ | 0..1 | CodeableConceptBinding | Element idProcedure.code Identification of the procedure Alternate namestype DefinitionThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). 0..1 to account for primarily narrative only resources. A code to identify a specific procedure. Procedure Codes (SNOMED CT) (preferred)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.code.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Procedure Code (extensible)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.code.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.code.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.code.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ | 1..1 | Reference(Group | CareConnect-Patient-1) | Element idProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. Reference(Group | CareConnect-Patient-1) Mappings
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| context | Σ | 0..1 | Reference(EpisodeOfCare | CareConnect-Encounter-1) | Element idProcedure.context Encounter or episode associated with the procedure Alternate namesencounter DefinitionThe encounter during which the procedure was performed. Reference(EpisodeOfCare | CareConnect-Encounter-1) Mappings
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| performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x] Date/Period the procedure was performed DefinitionThe date(time)/period over which 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.
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| performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| performedPeriod | Period | There are no (further) constraints on this element Data type | ||
| 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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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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.
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| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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| role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.role The role the actor was in DefinitionFor example: surgeon, anaethetist, endoscopist. A code that identifies the role of a performer of the procedure. Procedure Performer Role Codes (example)Mappings
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| actor | Σ | 1..1 | Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) | Element idProcedure.performer.actor The reference to the practitioner DefinitionThe practitioner who was involved in the procedure. A reference to Device supports use cases, such as pacemakers. Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) Mappings
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| onBehalfOf | 0..1 | Reference(CareConnect-Organization-1) | 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. Reference(CareConnect-Organization-1) Mappings
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| location | Σ | 0..1 | Reference(CareConnect-Location-1) | Element idProcedure.location Where the procedure happened DefinitionThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Ties a procedure to where the records are likely kept. Reference(CareConnect-Location-1) Mappings
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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 coded entity of some type, or may simply be present as text. A code that identifies the reason a procedure is required. Procedure Reason Codes (example)Mappings
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| reasonReference | Σ | 0..* | Reference(CareConnect-Observation-1 | CareConnect-Condition-1) | Element idProcedure.reasonReference Condition that is the reason the procedure performed DefinitionThe condition that is the reason why the procedure was performed. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. Reference(CareConnect-Observation-1 | CareConnect-Condition-1) Mappings
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.bodySite Target body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.bodySite.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Body Site (extensible)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.bodySite.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.bodySite.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.bodySite.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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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 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. Procedure Outcome Codes (SNOMED CT) (example)Mappings
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| report | 0..* | Reference(DiagnosticReport) | There are no (further) constraints on this element 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.
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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/Diagnosis Codes (example)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.complication.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.complication.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.complication.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Condition Code (required)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.complication.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.complication.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.complication.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| complicationDetail | 0..* | Reference(CareConnect-Condition-1) | 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. Reference(CareConnect-Condition-1) Mappings
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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 followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used. Specific follow up required for a procedure e.g. removal of sutures. Procedure Follow up Codes (SNOMED CT) (example)Mappings
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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 about the procedure. E.g. the operative notes.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.note.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.note.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| author[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation.
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| authorString | string | Data type | ||
| authorReference | Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1) | Data type Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1) | ||
| time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
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| text | 1..1 | string | There are no (further) constraints on this element Element idProcedure.note.text The annotation - text content DefinitionThe text of the annotation.
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| focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice Device changed in procedure 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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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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.
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| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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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. A kind of change that happened to the device during the procedure. Procedure Device Action Codes (preferred)Mappings
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| manipulated | 1..1 | Reference(Device) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated Device that was changed DefinitionThe device that was manipulated (changed) during the procedure.
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| usedReference | 0..* | Reference(Device | Substance | CareConnect-Medication-1) | 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 | Substance | CareConnect-Medication-1) Mappings
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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 FHIR Device Types (example)Mappings
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| CareConnect-Procedure-1 (Procedure) | I | Procedure | There are no (further) constraints on this element Element idProcedure An action that is being or was performed on a patient DefinitionAn action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. |
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language. Common Languages (extensible) | |
| text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
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| extension | 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. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Mappings
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| anaestheticIssues | I | 0..1 | Extension(Reference(CareConnect-Condition-1), CodeableConcept) | Element idProcedure.extension:anaestheticIssues Details of any adverse reaction to any anaesthetic agents Alternate namesextensions, user content DefinitionDetails of any adverse reaction to any anaesthetic agents. 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. Extension(Reference(CareConnect-Condition-1), CodeableConcept) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-AnaestheticIssues-1 Constraints
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| modifierExtension | ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier External Identifiers for this procedure DefinitionThis records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). Need to allow connection to a wider workflow.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.identifier.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.identifier.use usual | official | temp | secondary (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . IdentifierUse (required)Mappings
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible)Mappings
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.identifier.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. General http://www.acme.com/identifiers/patient Mappings
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| value | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. General 123456 Mappings
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedure.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
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| assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Element idProcedure.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. Reference(CareConnect-Organization-1) Mappings
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| definition | Σ | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | There are no (further) constraints on this element Element idProcedure.definition Instantiates protocol or definition DefinitionA protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure. Reference(PlanDefinition | ActivityDefinition | HealthcareService) Mappings
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| basedOn | Σ | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. Reference(CarePlan | ProcedureRequest | ReferralRequest) Mappings
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| partOf | Σ | 0..* | Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) | Element idProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, the anesthesia related medicationAdministration is part of the procedure. For an IV medication administration, the procedure to insert the IV port is part of the medication administration. Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) Mappings
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.status preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally this will be in-progress or completed state. 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)Mappings
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| notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDone True if procedure was not performed as scheduled DefinitionSet this to true if the record is saying that the procedure was NOT performed. If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome. This element is labeled as a modifier because it indicates that a procedure didn't happen. false
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| notDoneReason | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReason Reason procedure was not performed DefinitionA code indicating why the procedure was not performed. A code that identifies the reason a procedure was not performed. Procedure Not Performed Reason (SNOMED-CT) (example)Mappings
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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"). A code that classifies a procedure for searching, sorting and display purposes. Procedure Category Codes (SNOMED CT) (example)Mappings
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| code | Σ | 0..1 | CodeableConceptBinding | Element idProcedure.code Identification of the procedure Alternate namestype DefinitionThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). 0..1 to account for primarily narrative only resources. A code to identify a specific procedure. Procedure Codes (SNOMED CT) (preferred)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.code.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Procedure Code (extensible)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.code.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.code.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.code.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ | 1..1 | Reference(Group | CareConnect-Patient-1) | Element idProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. Reference(Group | CareConnect-Patient-1) Mappings
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| context | Σ | 0..1 | Reference(EpisodeOfCare | CareConnect-Encounter-1) | Element idProcedure.context Encounter or episode associated with the procedure Alternate namesencounter DefinitionThe encounter during which the procedure was performed. Reference(EpisodeOfCare | CareConnect-Encounter-1) Mappings
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| performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x] Date/Period the procedure was performed DefinitionThe date(time)/period over which 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.
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| performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| performedPeriod | Period | There are no (further) constraints on this element Data type | ||
| 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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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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.
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| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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| role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.role The role the actor was in DefinitionFor example: surgeon, anaethetist, endoscopist. A code that identifies the role of a performer of the procedure. Procedure Performer Role Codes (example)Mappings
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| actor | Σ | 1..1 | Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) | Element idProcedure.performer.actor The reference to the practitioner DefinitionThe practitioner who was involved in the procedure. A reference to Device supports use cases, such as pacemakers. Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) Mappings
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| onBehalfOf | 0..1 | Reference(CareConnect-Organization-1) | 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. Reference(CareConnect-Organization-1) Mappings
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| location | Σ | 0..1 | Reference(CareConnect-Location-1) | Element idProcedure.location Where the procedure happened DefinitionThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Ties a procedure to where the records are likely kept. Reference(CareConnect-Location-1) Mappings
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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 coded entity of some type, or may simply be present as text. A code that identifies the reason a procedure is required. Procedure Reason Codes (example)Mappings
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| reasonReference | Σ | 0..* | Reference(CareConnect-Observation-1 | CareConnect-Condition-1) | Element idProcedure.reasonReference Condition that is the reason the procedure performed DefinitionThe condition that is the reason why the procedure was performed. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. Reference(CareConnect-Observation-1 | CareConnect-Condition-1) Mappings
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.bodySite Target body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.bodySite.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Body Site (extensible)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.bodySite.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.bodySite.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.bodySite.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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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 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. Procedure Outcome Codes (SNOMED CT) (example)Mappings
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| report | 0..* | Reference(DiagnosticReport) | There are no (further) constraints on this element 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.
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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/Diagnosis Codes (example)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.complication.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.complication.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.complication.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Condition Code (required)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.complication.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.complication.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.complication.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| complicationDetail | 0..* | Reference(CareConnect-Condition-1) | 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. Reference(CareConnect-Condition-1) Mappings
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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 followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used. Specific follow up required for a procedure e.g. removal of sutures. Procedure Follow up Codes (SNOMED CT) (example)Mappings
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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 about the procedure. E.g. the operative notes.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.note.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.note.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| author[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation.
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| authorString | string | Data type | ||
| authorReference | Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1) | Data type Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1) | ||
| time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
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| text | 1..1 | string | There are no (further) constraints on this element Element idProcedure.note.text The annotation - text content DefinitionThe text of the annotation.
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| focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice Device changed in procedure 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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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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.
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| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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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. A kind of change that happened to the device during the procedure. Procedure Device Action Codes (preferred)Mappings
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| manipulated | 1..1 | Reference(Device) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated Device that was changed DefinitionThe device that was manipulated (changed) during the procedure.
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| usedReference | 0..* | Reference(Device | Substance | CareConnect-Medication-1) | 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 | Substance | CareConnect-Medication-1) Mappings
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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 FHIR Device Types (example)Mappings
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| CareConnect-Procedure-1 (Procedure) | I | Procedure | There are no (further) constraints on this element Element idProcedure An action that is being or was performed on a patient DefinitionAn action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.
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| id | Σ | 0..1 | id | There are no (further) constraints on this element Element idProcedure.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idProcedure.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource. |
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idProcedure.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. |
| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language. Common Languages (extensible) | |
| text | I | 0..1 | Narrative | There are no (further) constraints on this element Element idProcedure.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idProcedure.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.
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| extension | 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. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Mappings
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| anaestheticIssues | I | 0..1 | Extension(Reference(CareConnect-Condition-1), CodeableConcept) | Element idProcedure.extension:anaestheticIssues Details of any adverse reaction to any anaesthetic agents Alternate namesextensions, user content DefinitionDetails of any adverse reaction to any anaesthetic agents. 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. Extension(Reference(CareConnect-Condition-1), CodeableConcept) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-AnaestheticIssues-1 Constraints
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| modifierExtension | ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idProcedure.identifier External Identifiers for this procedure DefinitionThis records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). Need to allow connection to a wider workflow.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.identifier.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.identifier.use usual | official | temp | secondary (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . IdentifierUse (required)Mappings
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible)Mappings
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| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element idProcedure.identifier.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. General http://www.acme.com/identifiers/patient Mappings
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| value | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.identifier.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. General 123456 Mappings
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| period | Σ | 0..1 | Period | There are no (further) constraints on this element Element idProcedure.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use.
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| assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Element idProcedure.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. Reference(CareConnect-Organization-1) Mappings
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| definition | Σ | 0..* | Reference(PlanDefinition | ActivityDefinition | HealthcareService) | There are no (further) constraints on this element Element idProcedure.definition Instantiates protocol or definition DefinitionA protocol, guideline, orderset or other definition that was adhered to in whole or in part by this procedure. Reference(PlanDefinition | ActivityDefinition | HealthcareService) Mappings
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| basedOn | Σ | 0..* | Reference(CarePlan | ProcedureRequest | ReferralRequest) | There are no (further) constraints on this element Element idProcedure.basedOn A request for this procedure Alternate namesfulfills DefinitionA reference to a resource that contains details of the request for this procedure. Reference(CarePlan | ProcedureRequest | ReferralRequest) Mappings
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| partOf | Σ | 0..* | Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) | Element idProcedure.partOf Part of referenced event Alternate namescontainer DefinitionA larger event of which this particular procedure is a component or step. The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For a surgical procedure, the anesthesia related medicationAdministration is part of the procedure. For an IV medication administration, the procedure to insert the IV port is part of the medication administration. Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) Mappings
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idProcedure.status preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown DefinitionA code specifying the state of the procedure. Generally this will be in-progress or completed state. 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)Mappings
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| notDone | Σ ?! | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.notDone True if procedure was not performed as scheduled DefinitionSet this to true if the record is saying that the procedure was NOT performed. If true, it means the procedure did not occur as described. Typically it would be accompanied by attributes describing the type of activity. It might also be accompanied by body site information or time information (i.e. no procedure was done to the left arm or no procedure was done in this 2-year period). Specifying additional information such as performer, outcome, etc. is generally inappropriate. For example, it's not that useful to say "There was no appendectomy done at 12:03pm June 6th by Dr. Smith with a successful outcome" as it implies that there could have been an appendectomy done at any other time, by any other clinician or with any other outcome. This element is labeled as a modifier because it indicates that a procedure didn't happen. false
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| notDoneReason | Σ I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.notDoneReason Reason procedure was not performed DefinitionA code indicating why the procedure was not performed. A code that identifies the reason a procedure was not performed. Procedure Not Performed Reason (SNOMED-CT) (example)Mappings
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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"). A code that classifies a procedure for searching, sorting and display purposes. Procedure Category Codes (SNOMED CT) (example)Mappings
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| code | Σ | 0..1 | CodeableConceptBinding | Element idProcedure.code Identification of the procedure Alternate namestype DefinitionThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). 0..1 to account for primarily narrative only resources. A code to identify a specific procedure. Procedure Codes (SNOMED CT) (preferred)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.code.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Procedure Code (extensible)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.code.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.code.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.code.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ | 1..1 | Reference(Group | CareConnect-Patient-1) | Element idProcedure.subject Who the procedure was performed on Alternate namespatient DefinitionThe person, animal or group on which the procedure was performed. Reference(Group | CareConnect-Patient-1) Mappings
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| context | Σ | 0..1 | Reference(EpisodeOfCare | CareConnect-Encounter-1) | Element idProcedure.context Encounter or episode associated with the procedure Alternate namesencounter DefinitionThe encounter during which the procedure was performed. Reference(EpisodeOfCare | CareConnect-Encounter-1) Mappings
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| performed[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.performed[x] Date/Period the procedure was performed DefinitionThe date(time)/period over which 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.
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| performedDateTime | dateTime | There are no (further) constraints on this element Data type | ||
| performedPeriod | Period | There are no (further) constraints on this element Data type | ||
| 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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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.performer.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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.
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| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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| role | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.role The role the actor was in DefinitionFor example: surgeon, anaethetist, endoscopist. A code that identifies the role of a performer of the procedure. Procedure Performer Role Codes (example)Mappings
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| actor | Σ | 1..1 | Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) | Element idProcedure.performer.actor The reference to the practitioner DefinitionThe practitioner who was involved in the procedure. A reference to Device supports use cases, such as pacemakers. Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) Mappings
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| onBehalfOf | 0..1 | Reference(CareConnect-Organization-1) | 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. Reference(CareConnect-Organization-1) Mappings
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| location | Σ | 0..1 | Reference(CareConnect-Location-1) | Element idProcedure.location Where the procedure happened DefinitionThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Ties a procedure to where the records are likely kept. Reference(CareConnect-Location-1) Mappings
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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 coded entity of some type, or may simply be present as text. A code that identifies the reason a procedure is required. Procedure Reason Codes (example)Mappings
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| reasonReference | Σ | 0..* | Reference(CareConnect-Observation-1 | CareConnect-Condition-1) | Element idProcedure.reasonReference Condition that is the reason the procedure performed DefinitionThe condition that is the reason why the procedure was performed. e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. Reference(CareConnect-Observation-1 | CareConnect-Condition-1) Mappings
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| bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idProcedure.bodySite Target body sites DefinitionDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.bodySite.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.bodySite.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Body Site (extensible)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.bodySite.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.bodySite.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.bodySite.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.bodySite.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.bodySite.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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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 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. Procedure Outcome Codes (SNOMED CT) (example)Mappings
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| report | 0..* | Reference(DiagnosticReport) | There are no (further) constraints on this element 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.
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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/Diagnosis Codes (example)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.complication.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| coding | Σ | 0..* | Coding | Element idProcedure.complication.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Mappings
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| snomedCT | Σ | 0..1 | CodingBinding | Element idProcedure.complication.coding:snomedCT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. A code from the SNOMED Clinical Terminology UK. Care Connect Condition Code (required)Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | Element idProcedure.complication.coding:snomedCT.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| snomedCTDescriptionID | I | 0..1 | Extension(Complex) | Element idProcedure.complication.coding:snomedCT.extension:snomedCTDescriptionID The SNOMED CT Description ID for the display Alternate namesextensions, user content DefinitionThe SNOMED CT Description ID for the display. 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. Extension(Complex) Extension URLhttps://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid Constraints
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| system | Σ | 1..1 | uriFixed Value | Element idProcedure.complication.coding:snomedCT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. http://snomed.info/sct
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system.
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| display | Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.complication.coding:snomedCT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.complication.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| complicationDetail | 0..* | Reference(CareConnect-Condition-1) | 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. Reference(CareConnect-Condition-1) Mappings
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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 followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used. Specific follow up required for a procedure e.g. removal of sutures. Procedure Follow up Codes (SNOMED CT) (example)Mappings
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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 about the procedure. E.g. the operative notes.
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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.note.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.note.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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) Extensions are always sliced by (at least) url Mappings
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| author[x] | Σ | 0..1 | There are no (further) constraints on this element Element idProcedure.note.author[x] Individual responsible for the annotation DefinitionThe individual responsible for making the annotation.
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| authorString | string | Data type | ||
| authorReference | Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1) | Data type Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1) | ||
| time | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idProcedure.note.time When the annotation was made DefinitionIndicates when this particular annotation was made.
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| text | 1..1 | string | There are no (further) constraints on this element Element idProcedure.note.text The annotation - text content DefinitionThe text of the annotation.
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| focalDevice | 0..* | BackboneElement | There are no (further) constraints on this element Element idProcedure.focalDevice Device changed in procedure 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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| id | 0..1 | string | There are no (further) constraints on this element Element idProcedure.focalDevice.id xml:id (or equivalent in JSON) Definitionunique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.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 element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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.
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| modifierExtension | Σ ?! | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. 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.
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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. A kind of change that happened to the device during the procedure. Procedure Device Action Codes (preferred)Mappings
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| manipulated | 1..1 | Reference(Device) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated Device that was changed DefinitionThe device that was manipulated (changed) during the procedure.
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| usedReference | 0..* | Reference(Device | Substance | CareConnect-Medication-1) | 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 | Substance | CareConnect-Medication-1) Mappings
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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 FHIR Device Types (example)Mappings
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| Procedure | .. | |
| Procedure.extension | 0.. | |
| Procedure.extension | Extension | 0.. |
| Procedure.identifier | .. | |
| Procedure.identifier.system | 1.. | |
| Procedure.identifier.value | 1.. | |
| Procedure.identifier.assigner | Reference(CareConnect-Organization-1) | .. |
| Procedure.partOf | Reference(MedicationAdministration | CareConnect-Procedure-1 | CareConnect-Observation-1) | .. |
| Procedure.code | .. | |
| Procedure.code.coding | .. | |
| Procedure.code.coding | ..1 | |
| Procedure.code.coding.extension | 0.. | |
| Procedure.code.coding.extension | Extension | 0.. |
| Procedure.code.coding.system | 1.. | |
| Procedure.code.coding.code | 1.. | |
| Procedure.code.coding.display | 1.. | |
| Procedure.subject | Reference(Group | CareConnect-Patient-1) | .. |
| Procedure.context | Reference(EpisodeOfCare | CareConnect-Encounter-1) | .. |
| Procedure.performer | .. | |
| Procedure.performer.actor | Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnect-Patient-1 | CareConnect-Practitioner-1) | .. |
| Procedure.performer.onBehalfOf | Reference(CareConnect-Organization-1) | .. |
| Procedure.location | Reference(CareConnect-Location-1) | .. |
| Procedure.reasonReference | Reference(CareConnect-Observation-1 | CareConnect-Condition-1) | .. |
| Procedure.bodySite | .. | |
| Procedure.bodySite.coding | .. | |
| Procedure.bodySite.coding | ..1 | |
| Procedure.bodySite.coding.extension | 0.. | |
| Procedure.bodySite.coding.extension | Extension | 0.. |
| Procedure.bodySite.coding.system | 1.. | |
| Procedure.bodySite.coding.code | 1.. | |
| Procedure.bodySite.coding.display | 1.. | |
| Procedure.complication | .. | |
| Procedure.complication.coding | .. | |
| Procedure.complication.coding | ..1 | |
| Procedure.complication.coding.extension | 0.. | |
| Procedure.complication.coding.extension | Extension | 0.. |
| Procedure.complication.coding.system | 1.. | |
| Procedure.complication.coding.code | 1.. | |
| Procedure.complication.coding.display | 1.. | |
| Procedure.complicationDetail | Reference(CareConnect-Condition-1) | .. |
| Procedure.note | .. | |
| Procedure.note.author[x] | Reference(RelatedPerson | CareConnect-Patient-1 | CareConnect-Practitioner-1), string | .. |
| Procedure.usedReference | Reference(Device | Substance | CareConnect-Medication-1) | .. |
There is no specific guidance for this profile.
