ProcedureRequest resource implementation guidance
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ProcedureRequest: Implementation Guidance
Usage
Within the Clinical Decision Support API implementation, the ProcedureRequest resource will be used to carry details of a request for a procedure to be planned, proposed or performed with or on a patient.
The ProcedureRequest is referenced from ReferralRequest.basedOn and will be the diagnostic discriminator, or service requirement; diagnostic discriminator is a description of the next procedure which SHOULD be carried out in the referee service to validate or eliminate the chief concern.
Detailed implementation guidance for a ProcedureRequest resource in the CDS context is given below:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
identifier |
0..1 |
Identifier | Identifiers assigned to this order | Business identifier |
definition |
0..* |
Reference (ActivityDefinition | PlanDefinition) |
Protocol or definition | This MAY be populated with an ActivityDefinition, if a standard template for the ProcedureRequest has been defined in the local implementation. |
basedOn |
0..* |
Reference (Any) |
What request fulfils | This MAY be populated with a reference to a CarePlan, where the ProcedureRequest is based on recommendations in a relevant CarePlan. |
replaces |
0..* |
Reference (Any) |
What request replaces | |
requisition |
0..1 |
Identifier | Composite Request ID | |
status |
1..1 |
code | draft | active | suspended | completed | entered-in-error | cancelled RequestStatus (Required) | This SHOULD carry the value 'active'. |
intent |
1..1 |
code | proposal | plan | order + RequestIntent (Required) | The value carried in this element shows whether the request is a proposal, plan, an original order or a reflex order. It SHOULD carry the value 'proposal'. |
priority |
0..1 |
code | routine | |
This SHOULD be populated by the CDSS. In most cases, this will be populated with the code 'routine', indicating that the request is of normal priority. |
doNotPerform |
0..1 |
boolean | True if procedure should not be performed | |
category |
0..* |
CodeableConcept | Classification of procedure Procedure Category Codes (SNOMED CT) (Example) | This MAY be populated by the CDSS with a code that classifies the procedure for searching, sorting and display purposes. |
code |
1..1 |
CodeableConcept | What is being requested/ordered Procedure Codes (SNOMED CT) (Example) | This SHOULD be populated by the CDSS with a code that identifies the particular procedure which has been requested. |
subject |
1..1 |
Reference (Patient | Group | Location | Device) |
Individual the service is ordered for | This MUST be populated with a reference to the Patient resource. |
context |
0..1 |
Reference (Encounter | EpisodeOfCare) |
Encounter or Episode during which request was created | This MUST be populated with a reference to the Encounter supplied in the ServiceDefinition.$evaluate operation. |
occurrence[x] |
0..1 |
dateTime | Period | Timing |
When procedure should occur | |
asNeeded[x] |
0..1 |
boolean | CodeableConcept |
Preconditions for procedure or diagnostic SNOMED CT Medication As Needed Reason Codes (Example) | |
authoredOn |
0..1 |
dateTime | Date request signed | |
requester |
0..1 |
BackboneElement | Who/what is requesting procedure or diagnostic | This element SHOULD NOT be populated. |
requester.agent |
1..1 |
Reference (Device | Practitioner | Organization) |
Individual making the request | |
requester.onBehalfOf |
0..1 |
Reference (Organization) |
Organization agent is acting for | |
performerType |
0..1 |
CodeableConcept | Performer role Participant Roles (Example) | |
performer |
0..1 |
Reference (Practitioner | Organization | Patient | Device | RelatedPerson | HealthcareService) |
Requested perfomer | |
reasonCode |
0..* |
CodeableConcept | Explanation/Justification for test Procedure Reason Codes (Example) | This SHOULD NOT be populated as the reasonReference element will carry the chief concern. |
reasonReference |
0..* |
Reference (Condition | Observation) |
Explanation/Justification for test | This SHOULD be populated by the CDSS. The chief concern SHOULD be carried in this element. |
supportingInfo |
0..* |
Reference (Any) |
Additional clinical information | This SHOULD be populated by the CDSS. Secondary concerns SHOULD be be carried in this element. |
specimen |
0..* |
Reference (Specimen) |
Procedure Samples | |
bodySite |
0..* |
CodeableConcept | Location on Body SNOMED CT Body Structures (Example) | |
note |
0..* |
Annotation | Comments | This SHOULD be populated by the CDSS. |
relevantHistory |
0..* |
Reference (Provenance) |
Request provenance | This SHOULD be populated by the CDSS. |
