Procedure resource implementation guidance
Important: This site is under active development by NHS Digital and is intended to provide all the technical resources you need to successfully develop applications using the FHIR® CDS API.
Procedure: Implementation Guidance
Usage
The Procedure resource represents an action performed on a patient, which can be either an intrusive intervention (e.g. operation) or a less invasive one (e.g. counselling).
Detailed implementation guidance for a Procedure within the scope of this implementation guide is given below:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
id |
0..1 |
id | Logical id of this artifact | |
meta |
0..1 |
Meta | Metadata about the resource | |
implicitRules |
0..1 |
uri | A set of rules under which this content was created | |
language |
0..1 |
code | Language of the resource content. Common Languages (Extensible but limited to All Languages) |
|
text |
0..1 |
Narrative | Text summary of the resource, for human interpretation | |
contained |
0..* |
Resource | Contained, inline Resources | This SHOULD NOT be populated |
extension |
0..* |
Extension | Additional Content defined by implementations | |
modifierExtension |
0..* |
Extension | Extensions that cannot be ignored | |
identifier |
0..* |
Identifier | Business identifier | |
definition |
0..* |
Reference(PlanDefinition | ActivityDefinition | HealthcareService) | Instantiates protocol or definition | |
basedOn |
0..* |
Reference(CarePlan | ProcedureRequest | ReferralRequest) | A request for this procedure | |
partOf |
0..* |
Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | |
status |
1..1 |
code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown EventStatus (Required) |
This MUST be populated with either 'suspended', 'aborted', 'completed' or 'entered-in-error'. |
notDone |
0..1 |
boolean | True if procedure was not performed as scheduled | This MUST NOT be populated |
notDoneReason |
0..1 |
CodeableConcept | Reason procedure was not performed Procedure Not Performed Reason (SNOMED-CT) (Example) |
This MUST NOT be populated |
category |
0..1 |
CodeableConcept | Classification of the procedure Procedure Category Codes (SNOMED CT) (Example) |
|
code |
0..1 |
CodeableConcept | Identification of the procedure Procedure Codes (SNOMED CT) (Example) |
|
subject |
1..1 |
Reference (Patient | Group) | Who the procedure was performed on | This MUST be the Patient |
context |
0..1 |
Reference (Encounter | EpisodeOfCare) | Encounter or episode associated with the procedure | This MUST be the Encounter |
performed[x] |
0..1 |
Date/Period the procedure was performed | ||
performedDateTime |
dateTime | |||
performedPeriod |
Period | |||
performer |
0..* |
BackboneElement | The people who performed the procedure | |
role |
0..1 |
CodeableConcept | The role the actor was in Procedure Performer Role Codes (Example) |
|
actor |
1..1 |
Reference(Practitioner | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | |
onBehalfOf |
0..1 |
Reference(Organization) | Organization the device or practitioner was acting for | |
location |
0..1 |
Reference(Location) | Where the procedure happened | |
reasonCode |
0..* |
CodeableConcept | Coded reason procedure performed Procedure Reason Codes (Example) |
|
reasonReference |
0..* |
Reference(Condition | Observation) | Condition that is the reason the procedure performed | |
bodySite |
0..* |
CodeableConcept | Target body sites SNOMED CT Body Structures (Example) |
|
outcome |
0..1 |
CodeableConcept | The result of procedure Procedure Outcome Codes (SNOMED CT) (Example) |
|
report |
0..* |
Reference(DiagnosticReport) | Any report resulting from the procedure | |
complication |
0..* |
CodeableConcept | Complication following the procedure Condition/Problem/Diagnosis Codes (Example) |
|
complicationDetail |
0..* |
Reference(Condition) | A condition that is a result of the procedure | |
followUp |
0..* |
CodeableConcept | Instructions for follow up Procedure Follow up Codes (SNOMED CT) (Example) |
|
note |
0..* |
Annotation | Additional information about the procedure | |
focalDevice |
0..* |
BackboneElement | Device changed in procedure | |
action |
0..1 |
CodeableConcept | Kind of change to device Procedure Device Action Codes (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 FHIR Device Types (Example) |
