This is the Continuous Integration Build of the USCoreR4 Implementation Guide, based on FHIR Version 3.6.0. See the Directory of published versions
StructureDefinition-us-core-procedure
This profile sets minimum expectations for the Procedure resource to record, search and fetch procedures associated with a patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.
Example Usage Scenarios:
The following are example usage scenarios for the US Core-Procedure profile:
- Query for procedures performed on a Patient
- Record a procedure performed on a Patient
Mandatory Data Elements and Terminology
The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.
Each Procedure must have:
- a status
- a code that identifies the type of procedure performed on the patient
- a patient
- when the procedure was performed
Profile specific implementation guidance:
-
Based upon the 2015 Edition Certification Requirements, either SNOMED-CT or CPT-4/HCPC procedure codes are required and ICD-10-PCS codes MAY be supported as translations to them. If choosing to primarily to dental procedures, the Code on Dental Procedures and Nomenclature (CDT Code) may be used.
-
This profile may be referenced by different capability statements, such as the Conformance requirements for the US Core Server.
Examples
Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is: http://hl7.org/fhir/us/core-r4/StructureDefinition/us-core-procedure
Published on Mon Aug 01 00:00:00 PDT 2016 as a active by HL7 US Realm Steering Committee.
This profile builds on Procedure
Complete Summary of the Mandatory Requirements
- One patient reference in
Procedure.subject - A status code in Procedure.status which has a required binding to:
- EventStatus value set.
- One Identification of the procedure in
Procedure.codewhich has:- a extensible + max valueset binding to the US Core Procedure Codes valueset (SNOMED CT or CPT-4/HCPC for procedures).
- MAY have a translation to ICD-10-PCS or Code on Dental Procedures and Nomenclature (CDT Codes).s
- A date or a time period in
Procedure.performedDateTimeorProcedure.performedPeriod
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 0..* | US Core Procedure Profile | ||
  status | S | 1..1 | code | Binding: EventStatus (required) |
 code | S | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (extensible) |
 subject | S | 1..1 | Reference(US Core Patient Profile) | |
  performed[x] | S | 1..1 | dateTime, Period | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | I | 0..* | US Core Procedure Profile | |
| id | Σ | 0..1 | id | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
 contained | 0..* | Resource | Contained, inline Resources | |
 extension | 0..* | Extension | Additional content defined by implementations | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition |
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event |
| status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) |
| code | SΣ | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (extensible) |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | SΣ | 1..1 | dateTime, Period | When the procedure was performed |
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure |
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure |
| performer | ΣI | 0..* | BackboneElement | The people who performed the procedure |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example) |
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example) |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example) |
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | I | 0..* | BackboneElement | Manipulated, implanted, or removed device |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred) | |
| manipulated | 1..1 | Reference(Device) | Device that was changed | |
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example) | |
| Documentation for this format | ||||
Differential View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | US Core Procedure Profile | ||
| status | S | 1..1 | code | Binding: EventStatus (required) |
| code | S | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (extensible) |
| subject | S | 1..1 | Reference(US Core Patient Profile) | |
| performed[x] | S | 1..1 | dateTime, Period | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | I | 0..* | US Core Procedure Profile | |
| id | Σ | 0..1 | id | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition |
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event |
| status | ?!SΣ | 1..1 | code | preparation | in-progress | not-done | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) |
| code | SΣ | 1..1 | CodeableConcept | SNOMED-CT | ICD-10 | CPT-4 Binding: US Core Procedure Codes (extensible) |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | SΣ | 1..1 | dateTime, Period | When the procedure was performed |
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure |
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure |
| performer | ΣI | 0..* | BackboneElement | The people who performed the procedure |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example) |
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner |
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example) |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example) |
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) | |
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) | |
| note | 0..* | Annotation | Additional information about the procedure | |
| focalDevice | I | 0..* | BackboneElement | Manipulated, implanted, or removed device |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred) | |
| manipulated | 1..1 | Reference(Device) | Device that was changed | |
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example) | |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
Quick Start
Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.
GET /Procedure?patient=[id]
Example: GET [base]/Procedure?patient=1291938
Support: Mandatory to support search by patient.
Implementation Notes: Search for all Procedures for a patient. Fetches a bundle of all Procedure resources for the specified patient. (how to search by reference).
GET /Procedure?patient=[id]&date=[date]{&date=[date]}
Example: GET [base]Procedure?example&date=ge2002
Example: GET [base]Procedure?example&date=ge2010$date=le2015
Support: Mandatory to support search by patient and date or period.
Implementation Notes: Search based on date. Fetches a bundle of all Procedure resources for the specified patient for a specified time period (how to search by reference) and (how to search by date).
USCoreR4 Version: 2.0.0 ®© FHIR Version: 3.6.0 generated on Mon, Nov 12, 2018 13:42-0800.
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