| MII_PR_Prozedur_Procedure (Procedure) | I | | Procedure | Element idShort description An action that is being or was performed on a patient Definition An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.
Procedure Constraints- dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty() - dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() - dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() - dom-6: A resource should have narrative for robust management
text.`div`.exists() - dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty() - proc-mii-1: Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden
code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
- rim: Entity. Role, or Act
- workflow: Event
- rim: Procedure[moodCode=EVN]
|
| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idShort description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
string |
| meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idShort description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Meta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idShort description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idShort description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
id Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idProcedure.meta.lastUpdated When the resource version last changed Definition When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
instant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| source | S Σ | 0..1 | uri | There are no (further) constraints on this element Element idShort description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idShort description Profiles this resource claims to conform to Definition Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
canonical(StructureDefinition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idShort description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding Binding Security Labels from the Healthcare Privacy and Security Classification System.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
|
| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idShort description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
|
| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idShort description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idShort description Language of the resource content Definition The 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).
code Binding CommonLanguages (preferred)Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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| text | | 0..1 | Narrative | There are no (further) constraints on this element Element idShort description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Narrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: N/A
- rim: Act.text?
|
| contained | | 0..* | Resource | There are no (further) constraints on this element Element idShort description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Resource Mappings- rim: Entity. Role, or Act
- rim: N/A
|
| extension | S I | 0..* | Extension | There are no (further) constraints on this element Element idShort description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| Dokumentationsdatum | S I | 0..1 | Extension(dateTime) | Element idProcedure.extension:Dokumentationsdatum Dokumentationsdatum der Prozedur Alternate names extensions, user content Definition Dokumentationsdatum der Prozedur, falls abweichend vom Durchführungsdatum
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(dateTime) Extension URL http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| durchfuehrungsabsicht | S I | 0..1 | Extension(Coding) | Element idProcedure.extension:durchfuehrungsabsicht Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources.
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(Coding) Extension URL https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.modifierExtension Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idShort description External Identifiers for this procedure Definition Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.
Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.
This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.
Identifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
- rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
- servd: Identifier
- workflow: Event.identifier
- w5: FiveWs.identifier
- v2: Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4
- rim: .id
|
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | There are no (further) constraints on this element Element idProcedure.instantiatesCanonical Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.instantiatesCanonical
- rim: .outboundRelationship[typeCode=DEFN].target
|
| instantiatesUri | Σ | 0..* | uri | There are no (further) constraints on this element Element idProcedure.instantiatesUri Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.instantiatesUri
- rim: .outboundRelationship[typeCode=DEFN].target
|
| basedOn | Σ I | 0..* | Reference(CarePlan | ServiceRequest) | There are no (further) constraints on this element Element idShort description A request for this procedure Alternate names fulfills Definition A reference to a resource that contains details of the request for this procedure.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(CarePlan | ServiceRequest) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.basedOn
- rim: .outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
|
| partOf | Σ I | 0..* | Reference(Procedure | Observation | MedicationAdministration) | There are no (further) constraints on this element Element idShort description Part of referenced event Alternate names container Definition A larger event of which this particular procedure is a component or step.
The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).
Reference(Procedure | Observation | MedicationAdministration) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.partOf
- rim: .inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
|
| status | S Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idShort description preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Definition A code specifying the state of the procedure. Generally, this will be the 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.
code Binding A code specifying the state of the procedure.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.status
- w5: FiveWs.status
- rim: statusCode
|
| statusReason | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idShort description Reason for current status Alternate names Suspended Reason, Cancelled Reason Definition Captures the reason for the current state of the procedure.
This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.
CodeableConcept Binding A code that identifies the reason a procedure was not performed.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.statusReason
- rim: .reason.Observation.value
|
| category | S Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idShort description Classification of the procedure Definition A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding A code that classifies a procedure for searching, sorting and display purposes.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- w5: FiveWs.class
- rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.category.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| coding | Σ | 0..* | Coding | Element idProcedure.category.coding Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| sct | S Σ | 0..1 | CodingBindingPattern | Element idProcedure.category.coding:sct Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding Binding MII_VS_Prozedur_OpsKategorien_SNOMEDCT (preferred) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://snomed.info/sct"
}- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.category.coding:sct.id Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.category.coding:sct.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idProcedure.category.coding:sct.system Identity of the terminology system Definition The 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 reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.category.coding:sct.version Version of the system - if relevant Definition The 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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.category.coding:sct.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.category.coding:sct.display Representation defined by the system Definition A 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.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.category.coding:sct.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
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.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idShort description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| code | S Σ I | 1..1 | CodeableConcept | Element idShort description Identification of the procedure Alternate names type Definition The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
0..1 to account for primarily narrative only resources.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding A code to identify a specific procedure .
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - sct-ops-1: Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden.
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.code
- w5: FiveWs.what[x]
- v2: OBR-44/OBR-45
- rim: .code
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idShort description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| coding | S Σ | 1..* | Coding | Element idShort description Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding Sliced: Unordered, Open, by $this(Pattern) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| ops | S Σ | 0..1 | CodingOPSBindingPattern | Element idProcedure.code.coding:ops A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
CodingOPS Binding OpsVS (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://fhir.de/CodeSystem/bfarm/ops"
}- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:ops.id Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding:ops.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| Seitenlokalisation | S I | 0..1 | Extension(Coding) | Element idProcedure.code.coding:ops.extension:Seitenlokalisation Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources.
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(Coding) Extension URL http://fhir.de/StructureDefinition/seitenlokalisation Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| system | S Σ | 1..1 | uriFixed ValuePattern | There are no (further) constraints on this element Element idProcedure.code.coding:ops.system Canonische CodeSystem URL für OPS Definition The 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 reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
http://fhir.de/CodeSystem/bfarm/ops - rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | S Σ | 1..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:ops.version Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie Verwendung von OPS ist die Angabe der Version zwingend erforderlich.
Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von OPS ein neues Codesystem darstellt.
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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | S Σ I | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:ops.code Der OPS-Code Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ops-regex: In code sind nur gültige OPS-Codes ohne Zusätze erlaubt
matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')
Mappings- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:ops.display Representation defined by the system Definition A 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.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:ops.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
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.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| sct | S Σ | 0..1 | CodingBindingPattern | Element idProcedure.code.coding:sct Code defined by a terminology system Definition A reference to a code defined by a terminology system.
Allows for alternative encodings within a code system, and translations to other code systems.
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.
Coding Binding MII_VS_Prozedur_Prozeduren_SNOMEDCT (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
{
"system": "http://snomed.info/sct"
}- rim: n/a
- v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim: CV
- orim: fhir:Coding rdfs:subClassOf dt:CDCoding
- v2: C*E.1-8, C*E.10-22
- rim: union(., ./translation)
- orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:sct.id Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.code.coding:sct.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idProcedure.code.coding:sct.system Identity of the terminology system Definition The 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 reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.3
- rim: ./codeSystem
- orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:sct.version Version of the system - if relevant Definition The 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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.7
- rim: ./codeSystemVersion
- orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idProcedure.code.coding:sct.code Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.1
- rim: ./code
- orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idProcedure.code.coding:sct.display Representation defined by the system Definition A 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.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.2 - but note this is not well followed
- rim: CV.displayName
- orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
|
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idProcedure.code.coding:sct.userSelected If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
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.
boolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: Sometimes implied by being first
- rim: CD.codingRationale
- orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
|
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idShort description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
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.
string Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: C*E.9. But note many systems use C*E.2 for this
- rim: ./originalText[mediaType/code="text/plain"]/data
- orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
|
| subject | S Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element idShort description Who the procedure was performed on Alternate names patient Definition The person, animal or group on which the procedure was performed.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Patient | Group) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.subject
- w5: FiveWs.subject[x]
- v2: PID-3
- rim: .participation[typeCode=SBJ].role
- w5: FiveWs.subject
|
| encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idShort description Encounter created as part of Definition The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
Reference(Encounter) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.context
- w5: FiveWs.context
- v2: PV1-19
- rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
|
| performed[x] | S Σ | 1..1 | | There are no (further) constraints on this element Element idShort description When the procedure was performed Definition Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.
Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.occurrence[x]
- w5: FiveWs.done[x]
- v2: OBR-7
- rim: .effectiveTime
|
| performedDateTime | | | dateTime | Data type dateTime |
| performedPeriod | | | Period | Data type Period |
| recorder | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idShort description Who recorded the procedure Definition Individual who recorded the record and takes responsibility for its content.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.author
- rim: .participation[typeCode=AUT].role
|
| asserter | Σ I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idShort description Person who asserts this procedure Definition Individual who is making the procedure statement.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.source
- rim: .participation[typeCode=INF].role
|
| performer | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description The people who performed the procedure Definition Limited to "real" people rather than equipment.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- workflow: Event.performer
- rim: .participation[typeCode=PRF]
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.performer.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| function | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idProcedure.performer.function Type of performance Definition Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.
Allows disambiguation of the types of involvement of different performers.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding A code that identifies the role of a performer of the procedure.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.performer.function
- v2: Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25
- rim: .functionCode
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| actor | Σ I | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | There are no (further) constraints on this element Element idProcedure.performer.actor The reference to the practitioner Definition The practitioner who was involved in the procedure.
A reference to Device supports use cases, such as pacemakers.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.performer.actor
- w5: FiveWs.actor
- v2: ORC-19/PRT-5
- rim: .role
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| onBehalfOf | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idProcedure.performer.onBehalfOf Organization the device or practitioner was acting for Definition The organization the device or practitioner was acting on behalf of.
Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .scoper
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| location | Σ I | 0..1 | Reference(Location) | There are no (further) constraints on this element Element idShort description Where the procedure happened Definition The 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.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Location) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- w5: FiveWs.where[x]
- rim: .participation[typeCode=LOC].role[classCode=SDLOC]
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| reasonCode | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Coded reason procedure performed Definition The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.
Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
CodeableConcept Binding A code that identifies the reason a procedure is required.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- workflow: Event.reasonCode
- w5: FiveWs.why[x]
- rim: .reasonCode
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| reasonReference | Σ I | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | There are no (further) constraints on this element Element idProcedure.reasonReference The justification that the procedure was performed Definition The justification of why the procedure was performed.
It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use).
Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- workflow: Event.reasonReference
- w5: FiveWs.why[x]
- rim: .reasonCode
|
| bodySite | S Σ | 0..* | CodeableConceptBinding | Element idShort description Target body sites Definition Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.
CodeableConcept Binding Codes describing anatomical locations. May include laterality.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- v2: OBX-20
- rim: .targetSiteCode
|
| outcome | Σ | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idShort description The result of procedure Definition The outcome of the procedure - did it resolve the reasons for the procedure being performed?
If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
CodeableConcept Binding An outcome of a procedure - whether it was resolved or otherwise.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .outboundRelationship[typeCode=OUT].target.text
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| report | I | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | There are no (further) constraints on this element Element idShort description Any report resulting from the procedure Definition This could be a histology result, pathology report, surgical report, etc.
There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.
Reference(DiagnosticReport | DocumentReference | Composition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
|
| complication | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Complication following the procedure Definition Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.
If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.
CodeableConcept Binding Codes describing complications that resulted from a procedure.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
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| complicationDetail | I | 0..* | Reference(Condition) | There are no (further) constraints on this element Element idProcedure.complicationDetail A condition that is a result of the procedure Definition Any complications that occurred during the procedure, or in the immediate post-performance period.
This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Condition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
|
| followUp | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Instructions for follow up Definition If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding Specific follow up required for a procedure e.g. removal of sutures.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
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| note | S | 0..* | Annotation | There are no (further) constraints on this element Element idShort description Additional information about the procedure Definition Any other notes and comments about the procedure.
For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
Annotation Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: N/A
- rim: Act
- workflow: Event.note
- v2: NTE
- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
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| focalDevice | | 0..* | BackboneElement | There are no (further) constraints on this element Element idShort description Manipulated, implanted, or removed device Definition A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.
BackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- rim: .participation[typeCode=DEV].role[classCode=MANU]
|
| id | | 0..1 | string | There are no (further) constraints on this element Element idShort description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
string Mappings |
| extension | I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.extension Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idProcedure.focalDevice.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
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 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()
|
| action | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idProcedure.focalDevice.action Kind of change to device Definition The kind of change that happened to the device during the procedure.
Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
CodeableConcept Binding A kind of change that happened to the device during the procedure.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
|
| manipulated | I | 1..1 | Reference(Device) | There are no (further) constraints on this element Element idProcedure.focalDevice.manipulated Device that was changed Definition The device that was manipulated (changed) during the procedure.
References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
Reference(Device) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .participation[typeCode=DEV].role[classCode=SDLOC]
|
| usedReference | I | 0..* | Reference(Device | Medication | Substance) | There are no (further) constraints on this element Element idShort description Items used during procedure Definition Identifies medications, devices and any other substance used as part of the procedure.
Used for tracking contamination, etc.
For devices actually implanted or removed, use Procedure.device.
Reference(Device | Medication | Substance) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
- rim: n/a
- rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
- rim: .participation[typeCode=DEV].role[classCode=MANU] or
.participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)
|
| usedCode | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idShort description Coded items used during the procedure Definition Identifies coded items that were used as part of the procedure.
For devices actually implanted or removed, use Procedure.device.
CodeableConcept Binding Codes describing items used during a procedure.
- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim: n/a
- v2: CE/CNE/CWE
- rim: CD
- orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
- rim: participation[typeCode=Dev].role[classCode=MANU]
|
