[DE] Modul Prozedur - Version 1.0 - IG

Element id

Procedure

Short description

An action that is being or was performed on a patient

Definition

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Data type

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/dimdi/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Procedure[moodCode=EVN]

S Σ

0..1

There are no (further) constraints on this element

Element id

Procedure.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

Procedure.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.meta.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

versionId

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.versionId

Short 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.

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

lastUpdated

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.lastUpdated

Short description

When the resource version last changed

Definition

When the resource last changed - e.g. when the version changed.

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

source

S Σ

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.source

Short 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.

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

profile

S Σ

0..*

There are no (further) constraints on this element

Element id

Procedure.meta.profile

Short description

Profiles this resource claims to conform to

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

security

0..*

CodingBinding

There are no (further) constraints on this element

Element id

Procedure.meta.security

Short 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.

Comments

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.

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..*

There are no (further) constraints on this element

Element id

Procedure.meta.tag

Short 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.

Comments

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.

Data type

Binding

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

CommonTags (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

There are no (further) constraints on this element

Element id

Procedure.implicitRules

Short description

A set of rules under which this content was created

Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

Procedure.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Data type

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

Procedure.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Procedure.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

Element id

Procedure.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

recordedDate

S C

0..1

Element id

Procedure.extension:recordedDate

Short description

Dokumentationsdatum der Prozedur

Alternate names

extensions, user content

Definition

Dokumentationsdatum der Prozedur, falls abweichend vom Durchführungsdatum

Comments

Data type

ExtensionDokumentationsdatum

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

durchfuehrungsabsicht

S C

0..1

Element id

Procedure.extension:durchfuehrungsabsicht

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Optional Extension Element - found in all resources.

Comments

Data type

ExtensionDurchfuehrungsabsicht

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Procedure.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

0..*

There are no (further) constraints on this element

Element id

Procedure.identifier

Short description

External Identifiers for this procedure

Definition

Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Requirements

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..*

canonical(ActivityDefinition | Measure | OperationDefinition | PlanDefinition | Questionnaire)

There are no (further) constraints on this element

Element id

Procedure.instantiatesCanonical

Short description

Instantiates FHIR protocol or definition

Definition

The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Comments

see Canonical References

Data type

canonical(ActivityDefinition | Measure | OperationDefinition | PlanDefinition | Questionnaire)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.instantiatesCanonical
rim: .outboundRelationship[typeCode=DEFN].target

instantiatesUri

0..*

There are no (further) constraints on this element

Element id

Procedure.instantiatesUri

Short description

Instantiates external protocol or definition

Definition

The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.instantiatesUri
rim: .outboundRelationship[typeCode=DEFN].target

basedOn

Σ C

0..*

There are no (further) constraints on this element

Element id

Procedure.basedOn

Short description

A request for this procedure

Alternate names

fulfills

Definition

A reference to a resource that contains details of the request for this procedure.

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 C

0..*

Reference(MedicationAdministration | Observation | Procedure)

There are no (further) constraints on this element

Element id

Procedure.partOf

Short description

Part of referenced event

Alternate names

container

Definition

A larger event of which this particular procedure is a component or step.

Comments

The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Data type

Reference(MedicationAdministration | Observation | Procedure)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 id

Procedure.status

Short description

Definition

A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Comments

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.

Data type

Binding

A code specifying the state of the procedure.

EventStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
rim: statusCode

statusReason

0..1

There are no (further) constraints on this element

Element id

Procedure.statusReason

Short description

Reason for current status

Alternate names

Suspended Reason, Cancelled Reason

Definition

Captures the reason for the current state of the procedure.

Comments

This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

Data type

ProcedureNotPerformedReason(SNOMED-CT) (example)

Binding

A code that identifies the reason a procedure was not performed.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

There are no (further) constraints on this element

Element id

Procedure.category

Short description

Classification of the procedure

Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Comments

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.

Data type

ProcedureCategoryCodes(SNOMEDCT) (example)

Binding

A code that classifies a procedure for searching, sorting and display purposes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.category.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

0..*

Element id

Procedure.category.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Data type

Slicing

Unordered, Open, by $this(Pattern)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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 id

Procedure.category.coding:sct

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

ValueSetSNOMED-Procedure-Category (preferred)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "system": "http://snomed.info/sct"
}

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

S Σ

1..1

uriPattern

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://snomed.info/sct

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.version

Short description

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.

Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.code

Short description

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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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 C

1..1

Element id

Procedure.code

Short description

Identification of the procedure

Alternate names

type

Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Requirements

0..1 to account for primarily narrative only resources.

Comments

Data type

ProcedureCodes(SNOMEDCT) (example)

Binding

A code to identify a specific procedure .

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
sct-ops-1: Entweder wird die Prozedur mit OPS oder SNOMED-CT kodiert.
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.code.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

S Σ

1..*

Element id

Procedure.code.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Slicing

Unordered, Open, by system(Pattern)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

CodingBinding

Element id

Procedure.code.coding:ops

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

http://fhir.de/ValueSet/dimdi/ops (required)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Procedure.code.coding:ops.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

seitenlokalisation

S C

0..1

Element id

Procedure.code.coding:ops.extension:seitenlokalisation

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Optional Extension Element - found in all resources.

Comments

Data type

ExtensionSeitenlokalisation

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

S Σ

1..1

uriPattern

Element id

Procedure.code.coding:ops.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://fhir.de/CodeSystem/dimdi/ops

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.code

Short description

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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

CodingBinding

Element id

Procedure.code.coding:sct

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

ValueSetSNOMEDProcedureCodes (required)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

S Σ

1..1

uriPattern

Element id

Procedure.code.coding:sct.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://snomed.info/sct

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.code

Short description

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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

Σ C

1..1

Element id

Procedure.subject

Short description

A reference from one resource to another

Alternate names

patient

Definition

A reference from one resource to another.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))
mii-reference-1: Either reference.reference OR reference.identifier exists
($this.reference.exists() or ($this.identifier.value.exists() and $this.identifier.system.exists())) xor $this.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()

Mappings

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 C

0..1

There are no (further) constraints on this element

Element id

Procedure.encounter

Short description

Encounter created as part of

Definition

The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 id

Procedure.performed[x]

Short 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.

Comments

Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
v2: OBR-7
rim: .effectiveTime

performedDateTime

Data type

performedPeriod

Data type

recorder

Σ C

0..1

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Procedure.recorder

Short description

Who recorded the procedure

Definition

Individual who recorded the record and takes responsibility for its content.

Comments

Data type

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 C

0..1

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Procedure.asserter

Short description

Person who asserts this procedure

Definition

Individual who is making the procedure statement.

Comments

Data type

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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

0..*

There are no (further) constraints on this element

Element id

Procedure.performer

Short description

The people who performed the procedure

Definition

Limited to "real" people rather than equipment.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.performer
rim: .participation[typeCode=PRF]

0..1

There are no (further) constraints on this element

Element id

Procedure.performer.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.performer.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Procedure.performer.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

function

0..1

There are no (further) constraints on this element

Element id

Procedure.performer.function

Short description

Type of performance

Definition

Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Requirements

Allows disambiguation of the types of involvement of different performers.

Comments

Data type

ProcedurePerformerRoleCodes (example)

Binding

A code that identifies the role of a performer of the procedure.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

actor

Σ C

1..1

There are no (further) constraints on this element

Element id

Procedure.performer.actor

Short description

The reference to the practitioner

Definition

The practitioner who was involved in the procedure.

Requirements

A reference to Device supports use cases, such as pacemakers.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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

onBehalfOf

0..1

There are no (further) constraints on this element

Element id

Procedure.performer.onBehalfOf

Short description

Organization the device or practitioner was acting for

Definition

The organization the device or practitioner was acting on behalf of.

Requirements

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .scoper

location

Σ C

0..1

There are no (further) constraints on this element

Element id

Procedure.location

Short description

Where the procedure happened

Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Requirements

Ties a procedure to where the records are likely kept.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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]

reasonCode

0..*

There are no (further) constraints on this element

Element id

Procedure.reasonCode

Short description

Coded reason procedure performed

Definition

The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Comments

Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Data type

ProcedureReasonCodes (example)

Binding

A code that identifies the reason a procedure is required.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

reasonReference

Σ C

0..*

Reference(Condition | DiagnosticReport | DocumentReference | Observation | Procedure)

There are no (further) constraints on this element

Element id

Procedure.reasonReference

Short description

The justification that the procedure was performed

Definition

The justification of why the procedure was performed.

Comments

It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Data type

Reference(Condition | DiagnosticReport | DocumentReference | Observation | Procedure)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 id

Procedure.bodySite

Short description

Target body sites

Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Data type

SNOMEDCTBodyStructures (extensible)

Binding

Codes describing anatomical locations. May include laterality.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
v2: OBX-20
rim: .targetSiteCode

outcome

0..1

There are no (further) constraints on this element

Element id

Procedure.outcome

Short description

The result of procedure

Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Data type

ProcedureOutcomeCodes(SNOMEDCT) (example)

Binding

An outcome of a procedure - whether it was resolved or otherwise.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=OUT].target.text

report

0..*

Reference(Composition | DiagnosticReport | DocumentReference)

There are no (further) constraints on this element

Element id

Procedure.report

Short description

Any report resulting from the procedure

Definition

This could be a histology result, pathology report, surgical report, etc.

Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Data type

Reference(Composition | DiagnosticReport | DocumentReference)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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..*

There are no (further) constraints on this element

Element id

Procedure.complication

Short description

Complication following the procedure

Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Data type

Condition/Problem/DiagnosisCodes (example)

Binding

Codes describing complications that resulted from a procedure.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

complicationDetail

0..*

There are no (further) constraints on this element

Element id

Procedure.complicationDetail

Short description

A condition that is a result of the procedure

Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Requirements

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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..*

There are no (further) constraints on this element

Element id

Procedure.followUp

Short description

Instructions for follow up

Definition

If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.

Comments

Data type

ProcedureFollowUpCodes(SNOMEDCT) (example)

Binding

Specific follow up required for a procedure e.g. removal of sutures.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

note

0..*

There are no (further) constraints on this element

Element id

Procedure.note

Short description

Additional information about the procedure

Definition

Any other notes and comments about the procedure.

Comments

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).

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

focalDevice

0..*

There are no (further) constraints on this element

Element id

Procedure.focalDevice

Short description

Manipulated, implanted, or removed device

Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode=DEV].role[classCode=MANU]

0..1

There are no (further) constraints on this element

Element id

Procedure.focalDevice.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.focalDevice.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Procedure.focalDevice.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

action

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Procedure.focalDevice.action

Short description

Kind of change to device

Definition

The kind of change that happened to the device during the procedure.

Comments

Data type

ProcedureDeviceActionCodes (preferred)

Binding

A kind of change that happened to the device during the procedure.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

1..1

There are no (further) constraints on this element

Element id

Procedure.focalDevice.manipulated

Short description

Device that was changed

Definition

The device that was manipulated (changed) during the procedure.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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

0..*

There are no (further) constraints on this element

Element id

Procedure.usedReference

Short description

Items used during procedure

Definition

Identifies medications, devices and any other substance used as part of the procedure.

Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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..*

There are no (further) constraints on this element

Element id

Procedure.usedCode

Short description

Coded items used during the procedure

Definition

Identifies coded items that were used as part of the procedure.

Comments

For devices actually implanted or removed, use Procedure.device.

Data type

Binding

Codes describing items used during a procedure.

FHIRDeviceTypes (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: participation[typeCode=Dev].role[classCode=MANU]

Hinweise

FHIR-Element	Erklärung
Procedure.id	Must-support, jedoch optional
Procedure.meta	Must-support, jedoch optional
Procedure.status	Keine Einschränkungen bezüglich des gewählten Status
Procedure.category	Verpflichtende SNOMED CT Kategorisierung auf Basis des Prozedurenkodes. Siehe Command 'pagelink' could not render: Object reference not set to an instance of an object. für ein Mapping von OPS Klassentitel auf SNOMED CT. Nur relevant falls die Prozedur per OPS kodiert wird, siehe proc-mii-1
Procedure.code	Verpflichtende Kodierung entweder per OPS oder SNOMED. Weitere Kodierungen erlaubt.
Procedure.code:ops	Siehe OPS-Kodierung - Deutsche Basisprofile
Procedure.performed[x]	Neben der Angabe als dateTime kann auch eine Period angegeben werden (falls Start- und Endzeitpunkt bekannt sind)
Procedure.bodySite	Detaillierte Kodierung der Körperstelle(n) der Prozedur. Sollte NICHT verwendet werden um die Lateralität der Prozedur abzubilden. Dies ist eine Eigenschaft des Kodes. Siehe Procedure.code:ops
Procedure.note	Freitextangaben zur Prozedur

Mapping

FHIR Element	Logischer Datensatz
Procedure.code:ops	Prozedur.OPSProzedurKodiert
Procedure.code:ops.coding.code	Prozedur.OPSProzedurKodiert.VollständigerProzedurenkode (Kode)
Procedure.code:ops.coding.system	Prozedur.OPSProzedurKodiert.VollständigerProzedurenkode (Kodesystem)
Procedure.code:ops.coding.version	Prozedur.OPSProzedurKodiert.VollständigerProzedurenkode (Version)
Procedure.code:ops.extension.seitenlokalisation	Prozedur.OPSProzedurKodiert.Seitenlokalisation
Procedure.code:sct	Prozedur.SNOMEDProzedurKodiert
Procedure.code:sct.code	Prozedur.SNOMEDProzedurKodiert.VollständigerProzedurenkode (Kode)
Procedure.code:sct.system	Prozedur.SNOMEDProzedurKodiert.VollständigerProzedurenkode (Kodesystem)
Procedure.bodySite	Prozedur.Körperstelle
Procedure.performed[x]	Prozedur.Durchführungsdatum
Procedure.note	Prozedur.Freitextbeschreibung
Procedure.extension.Dokumentationsdatum	Prozedur.Dokumentationsdatum
Procedure.extension.durchfuehrungsabsicht	Prozedur.Durchfuehrungsabsicht

Constraints

Folgende Invarianten müssen bei der Implementierung des Profils beachtet werden:

Constraints:

key	severity	human	expression
proc-mii-1	error	Falls die Prozedur per OPS kodiert wird, muss eine SNOMED-CT kodierte Category abgebildet werden	code.coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
sct-ops-1	error	Entweder wird die Prozedur mit OPS oder SNOMED-CT kodiert.	coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists()

Weitere Vorgaben werden durch die Profile für die Datentypen OPS durch die Deutschen Basisprofile gemacht.

Terminology Bindings

Path	Name	Strength	URL
Procedure.category.coding	procedures-category-sct	preferred	https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/ValueSet/procedures-category-sct
Procedure.code.coding	dimdi/ops	required	http://fhir.de/ValueSet/dimdi/ops
Procedure.code.coding	procedures-sct	required	https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/ValueSet/procedures-sct

Snapshot

ProfileProcedureProzedur (Procedure)

Element id

Procedure

Short description

An action that is being or was performed on a patient

Definition

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Data type

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/dimdi/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()

Mappings

rim: Entity. Role, or Act
workflow: Event
rim: Procedure[moodCode=EVN]

S Σ

0..1

There are no (further) constraints on this element

Element id

Procedure.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

Procedure.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.meta.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

versionId

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.versionId

Short 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.

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

lastUpdated

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.lastUpdated

Short description

When the resource version last changed

Definition

When the resource last changed - e.g. when the version changed.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

source

S Σ

0..1

There are no (further) constraints on this element

Element id

Procedure.meta.source

Short description

Identifies where the resource comes from

Definition

Comments

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

profile

S Σ

0..*

There are no (further) constraints on this element

Element id

Procedure.meta.profile

Short description

Profiles this resource claims to conform to

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

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.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

security

0..*

CodingBinding

There are no (further) constraints on this element

Element id

Procedure.meta.security

Short 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.

Comments

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.

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..*

There are no (further) constraints on this element

Element id

Procedure.meta.tag

Short description

Tags applied to this resource

Definition

Comments

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.

Data type

Binding

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

CommonTags (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

There are no (further) constraints on this element

Element id

Procedure.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

Procedure.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

Procedure.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

Procedure.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

Element id

Procedure.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

recordedDate

S C

0..1

Element id

Procedure.extension:recordedDate

Short description

Dokumentationsdatum der Prozedur

Alternate names

extensions, user content

Definition

Dokumentationsdatum der Prozedur, falls abweichend vom Durchführungsdatum

Comments

Data type

ExtensionDokumentationsdatum

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

durchfuehrungsabsicht

S C

0..1

Element id

Procedure.extension:durchfuehrungsabsicht

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Optional Extension Element - found in all resources.

Comments

Data type

ExtensionDurchfuehrungsabsicht

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

Procedure.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

0..*

There are no (further) constraints on this element

Element id

Procedure.identifier

Short description

External Identifiers for this procedure

Definition

Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Requirements

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..*

canonical(ActivityDefinition | Measure | OperationDefinition | PlanDefinition | Questionnaire)

There are no (further) constraints on this element

Element id

Procedure.instantiatesCanonical

Short description

Instantiates FHIR protocol or definition

Definition

The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Comments

see Canonical References

Data type

canonical(ActivityDefinition | Measure | OperationDefinition | PlanDefinition | Questionnaire)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.instantiatesCanonical
rim: .outboundRelationship[typeCode=DEFN].target

instantiatesUri

0..*

There are no (further) constraints on this element

Element id

Procedure.instantiatesUri

Short description

Instantiates external protocol or definition

Definition

The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.instantiatesUri
rim: .outboundRelationship[typeCode=DEFN].target

basedOn

Σ C

0..*

There are no (further) constraints on this element

Element id

Procedure.basedOn

Short description

A request for this procedure

Alternate names

fulfills

Definition

A reference to a resource that contains details of the request for this procedure.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 C

0..*

Reference(MedicationAdministration | Observation | Procedure)

There are no (further) constraints on this element

Element id

Procedure.partOf

Short description

Part of referenced event

Alternate names

container

Definition

A larger event of which this particular procedure is a component or step.

Comments

Data type

Reference(MedicationAdministration | Observation | Procedure)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 id

Procedure.status

Short description

Definition

A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Data type

Binding

A code specifying the state of the procedure.

EventStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
rim: statusCode

statusReason

0..1

There are no (further) constraints on this element

Element id

Procedure.statusReason

Short description

Reason for current status

Alternate names

Suspended Reason, Cancelled Reason

Definition

Captures the reason for the current state of the procedure.

Comments

This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

Data type

ProcedureNotPerformedReason(SNOMED-CT) (example)

Binding

A code that identifies the reason a procedure was not performed.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

There are no (further) constraints on this element

Element id

Procedure.category

Short description

Classification of the procedure

Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Comments

Data type

ProcedureCategoryCodes(SNOMEDCT) (example)

Binding

A code that classifies a procedure for searching, sorting and display purposes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.category.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

0..*

Element id

Procedure.category.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Slicing

Unordered, Open, by $this(Pattern)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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 id

Procedure.category.coding:sct

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

ValueSetSNOMED-Procedure-Category (preferred)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "system": "http://snomed.info/sct"
}

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

S Σ

1..1

uriPattern

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://snomed.info/sct

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.code

Short description

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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.coding:sct.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.category.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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 C

1..1

Element id

Procedure.code

Short description

Identification of the procedure

Alternate names

type

Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Requirements

0..1 to account for primarily narrative only resources.

Comments

Data type

ProcedureCodes(SNOMEDCT) (example)

Binding

A code to identify a specific procedure .

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
sct-ops-1: Entweder wird die Prozedur mit OPS oder SNOMED-CT kodiert.
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists()

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.code.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

S Σ

1..*

Element id

Procedure.code.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Slicing

Unordered, Open, by system(Pattern)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

CodingBinding

Element id

Procedure.code.coding:ops

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

http://fhir.de/ValueSet/dimdi/ops (required)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

Element id

Procedure.code.coding:ops.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

seitenlokalisation

S C

0..1

Element id

Procedure.code.coding:ops.extension:seitenlokalisation

Short description

Optional Extensions Element

Alternate names

extensions, user content

Definition

Optional Extension Element - found in all resources.

Comments

Data type

ExtensionSeitenlokalisation

Extension URL

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

S Σ

1..1

uriPattern

Element id

Procedure.code.coding:ops.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://fhir.de/CodeSystem/dimdi/ops

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.code

Short description

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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:ops.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

CodingBinding

Element id

Procedure.code.coding:sct

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

ValueSetSNOMEDProcedureCodes (required)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

S Σ

1..1

uriPattern

Element id

Procedure.code.coding:sct.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://snomed.info/sct

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.code

Short description

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).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.coding:sct.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

0..1

There are no (further) constraints on this element

Element id

Procedure.code.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

Σ C

1..1

Element id

Procedure.subject

Short description

A reference from one resource to another

Alternate names

patient

Definition

A reference from one resource to another.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))
mii-reference-1: Either reference.reference OR reference.identifier exists
($this.reference.exists() or ($this.identifier.value.exists() and $this.identifier.system.exists())) xor $this.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()

Mappings

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 C

0..1

There are no (further) constraints on this element

Element id

Procedure.encounter

Short description

Encounter created as part of

Definition

The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 id

Procedure.performed[x]

Short description

When the procedure was performed

Definition

Comments

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
v2: OBR-7
rim: .effectiveTime

performedDateTime

Data type

performedPeriod

Data type

recorder

Σ C

0..1

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Procedure.recorder

Short description

Who recorded the procedure

Definition

Individual who recorded the record and takes responsibility for its content.

Comments

Data type

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 C

0..1

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

There are no (further) constraints on this element

Element id

Procedure.asserter

Short description

Person who asserts this procedure

Definition

Individual who is making the procedure statement.

Comments

Data type

Reference(Patient | Practitioner | PractitionerRole | RelatedPerson)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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

0..*

There are no (further) constraints on this element

Element id

Procedure.performer

Short description

The people who performed the procedure

Definition

Limited to "real" people rather than equipment.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.performer
rim: .participation[typeCode=PRF]

0..1

There are no (further) constraints on this element

Element id

Procedure.performer.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.performer.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Procedure.performer.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

function

0..1

There are no (further) constraints on this element

Element id

Procedure.performer.function

Short description

Type of performance

Definition

Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Requirements

Allows disambiguation of the types of involvement of different performers.

Comments

Data type

ProcedurePerformerRoleCodes (example)

Binding

A code that identifies the role of a performer of the procedure.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

actor

Σ C

1..1

There are no (further) constraints on this element

Element id

Procedure.performer.actor

Short description

The reference to the practitioner

Definition

The practitioner who was involved in the procedure.

Requirements

A reference to Device supports use cases, such as pacemakers.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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

onBehalfOf

0..1

There are no (further) constraints on this element

Element id

Procedure.performer.onBehalfOf

Short description

Organization the device or practitioner was acting for

Definition

The organization the device or practitioner was acting on behalf of.

Requirements

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .scoper

location

Σ C

0..1

There are no (further) constraints on this element

Element id

Procedure.location

Short description

Where the procedure happened

Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Requirements

Ties a procedure to where the records are likely kept.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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]

reasonCode

0..*

There are no (further) constraints on this element

Element id

Procedure.reasonCode

Short description

Coded reason procedure performed

Definition

The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Comments

Data type

ProcedureReasonCodes (example)

Binding

A code that identifies the reason a procedure is required.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

reasonReference

Σ C

0..*

Reference(Condition | DiagnosticReport | DocumentReference | Observation | Procedure)

There are no (further) constraints on this element

Element id

Procedure.reasonReference

Short description

The justification that the procedure was performed

Definition

The justification of why the procedure was performed.

Comments

Data type

Reference(Condition | DiagnosticReport | DocumentReference | Observation | Procedure)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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 id

Procedure.bodySite

Short description

Target body sites

Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Data type

SNOMEDCTBodyStructures (extensible)

Binding

Codes describing anatomical locations. May include laterality.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
v2: OBX-20
rim: .targetSiteCode

outcome

0..1

There are no (further) constraints on this element

Element id

Procedure.outcome

Short description

The result of procedure

Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Data type

ProcedureOutcomeCodes(SNOMEDCT) (example)

Binding

An outcome of a procedure - whether it was resolved or otherwise.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
rim: .outboundRelationship[typeCode=OUT].target.text

report

0..*

Reference(Composition | DiagnosticReport | DocumentReference)

There are no (further) constraints on this element

Element id

Procedure.report

Short description

Any report resulting from the procedure

Definition

This could be a histology result, pathology report, surgical report, etc.

Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Data type

Reference(Composition | DiagnosticReport | DocumentReference)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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..*

There are no (further) constraints on this element

Element id

Procedure.complication

Short description

Complication following the procedure

Definition

Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Data type

Condition/Problem/DiagnosisCodes (example)

Binding

Codes describing complications that resulted from a procedure.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

complicationDetail

0..*

There are no (further) constraints on this element

Element id

Procedure.complicationDetail

Short description

A condition that is a result of the procedure

Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Requirements

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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..*

There are no (further) constraints on this element

Element id

Procedure.followUp

Short description

Instructions for follow up

Definition

Comments

Data type

ProcedureFollowUpCodes(SNOMEDCT) (example)

Binding

Specific follow up required for a procedure e.g. removal of sutures.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

note

0..*

There are no (further) constraints on this element

Element id

Procedure.note

Short description

Additional information about the procedure

Definition

Any other notes and comments about the procedure.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

focalDevice

0..*

There are no (further) constraints on this element

Element id

Procedure.focalDevice

Short description

Manipulated, implanted, or removed device

Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .participation[typeCode=DEV].role[classCode=MANU]

0..1

There are no (further) constraints on this element

Element id

Procedure.focalDevice.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

Procedure.focalDevice.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

Procedure.focalDevice.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

action

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

Procedure.focalDevice.action

Short description

Kind of change to device

Definition

The kind of change that happened to the device during the procedure.

Comments

Data type

ProcedureDeviceActionCodes (preferred)

Binding

A kind of change that happened to the device during the procedure.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

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

1..1

There are no (further) constraints on this element

Element id

Procedure.focalDevice.manipulated

Short description

Device that was changed

Definition

The device that was manipulated (changed) during the procedure.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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

0..*

There are no (further) constraints on this element

Element id

Procedure.usedReference

Short description

Items used during procedure

Definition

Identifies medications, devices and any other substance used as part of the procedure.

Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

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.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

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..*

There are no (further) constraints on this element

Element id

Procedure.usedCode

Short description

Coded items used during the procedure

Definition

Identifies coded items that were used as part of the procedure.

Comments

For devices actually implanted or removed, use Procedure.device.

Data type