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Procedures List

The FHIR profiles used for the Procedures List

Heading Description

The details of any procedures performed.

The following FHIR profiles are used to form the Personal comment List structure:

The following profiles are referenced from the Patient demographics list structure:

Procedures Structure

Page-1 Procedure Resource Procedure Resource ProcedureResource Reference from Procedures List to Procedure 0..* R entry.item 0..* R entry.item 0..* Rentry.item Procedures List Resource Procedures List Resource ProceduresList Resource 1..1 M subject 1..1 M subject 1..1 Msubject Reference to Patient resource Reference to Patient resource Reference to Patient resource Reference from Procedures List to Patient Reference from Procedures to patient 1..1 M subject 1..1 M subject 1..1 Msubject Organization Resource Organization Resource OrganizationResource Reference from Procedure to Organization 0..1 R performer.onBehalfOf 0..1 R performer. onBehalfOf 0..1 Rperformer.onBehalfOf Practitioner Resource Practitioner Resource PractitionerResource Reference from Procedure to Practitioner 0..1 R performer 0..1 R performer 0..1 Rperformer PractitionerRole Resource PractitionerRole Resource PractitionerRoleResource Reference from PractitionerRole to Practitioner 0..1 R practitioner 0..1 R practitioner 0..1 Rpractitioner

Maternity data standard Mapping to FHIR profiles

Mapping Overview

Data Standard Element FHIR Resource Mapping FHIR Element
Date/time Observation performed.performedDate
ODS/ORD Site Code Organization identifier
Name Practitioner name
SDS Job Role Name PractitionerRole code
Procedure Procedure code
Anatomical site Procedure bodySite
Laterality Procedure bodySite
Complications related to procedure Procedure complication
Specific anaesthesia issues Procedure Extension-CareConnect-AnaestheticIssues-1.value[x]
Comment Procedure note

The following tables detail how to populate the FHIR resources and the mapping to the Maternity data standard.

Mapping for Procedures List

> Level 1 List Resource > Level 2 CareConnect-List-1 > Level 3 None
View Used FHIR Elements View All FHIR Elements
Name Card. Conformance Type Description, Constraints and mapping for Implementation
List       Information summarized from a list of other resources
Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources
Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative
Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
Constraint (lst-2): The deleted flag can only be used if the mode of the list is “changes”
Constraint (lst-1): A list can only have an emptyReason if it is empty
- id 0..1 Optional Id Logical id of this artifact
- meta 0..1 Mandatory Meta Metadata about the resource
The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-List-1'
- identifier 0..* Required Identifier Business identifier
An identifier for this Procedures List

- - system 1..1 Required Uri The namespace for the identifier value
The system from which the identifier came
- - value 1..1 Mandatory String The value that is unique
A value for the identifier
- - assigner 0..1 Optional Reference Organization that issued id (may be just text)
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Optional CareConnect-Organization-1  
- - - reference 0..1 Optional String Literal reference, Relative, internal or absolute URL
- - - identifier 0..1 Optional Identifier Logical reference, when literal reference is not known
- - - display 0..1 Optional String Text alternative for the resource
- status 1..1 Mandatory Code current : retired : entered-in-error
Binding (required): The current state of the list ListStatus
The status of the list MUST contain the value 'current'
- mode 1..1 Mandatory Code working : snapshot : changes
Binding (required): The processing mode that applies to this list ListMode
The mode of the list MUST contain the value 'snapshot'
- title 0..1 Mandatory String Descriptive name for the list
This MUST contain the value 'Procedures'
Mapping to Maternity data item = 'PSRB Heading Procedures'
- code 0..1 Mandatory CodeableConcept What the purpose of this list is
Binding (preferred): What the purpose of a list is CareConnect-ListCode-1
The PRSB heading for this list. Note: for Maternity the value stated below is used which is not from the preferred value set
- - coding 0..* Mandatory Coding Code defined by a terminology system
The SNOMED CT concept for the PRSB heading type
- - - system 0..1 Mandatory Uri Identity of the terminology system
This MUST contain the value 'http://snomed.info/sct'
- - - code 0..1 Mandatory Code Symbol in syntax defined by the system
This MUST contain the value 'tbc'
- - - display 0..1 Mandatory String Representation defined by the system
This MUST contain the value 'Procedures'
Mapping to Maternity data item = 'PSRB Heading Procedures'
- subject 0..1 Mandatory Reference If all resources have the same subject
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
This is a reference to the Patient who is the subject of the list.
    Mandatory CareConnect-Patient-1 This is the subject of the Procedures List.
This MUST use the CareConnect patient profile.
See patient resource reference for information on how to populate the resource.
- - reference 0..1 Mandatory String Literal reference, Relative, internal or absolute URL
A reference to the patient resource included in the Patient demographics list within the FHIR Bundle. Note the Patient demographics list is mandatory in the FHIR bundle
- date 0..1 Mandatory dateTime When the list was prepared
This MUST contain a system date to indicate when the list created or updated
- note 0..* Optional Annotation Comments about the list
- - author[x] 0..1 Optional Reference Individual responsible for the annotation
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Optional CareConnect-Practitioner-1  
    Optional String Who authored the comment on the list.
- - time 0..1 Required dateTime When the annotation was made
- - text 1..1 Required String The annotation - text content
- entry 0..* Mandatory BackboneElement Entries in the list
The entries MUST be as per the diagram for this PRSB headings list with the Procedures resource being the focal resource.
- - date 0..1 Required dateTime When item added to list
The SHOULD contain a system time of when the item was added to the list.
- - item 1..1 Required Reference Actual entry
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
A reference to a Procedure resource included in the list
- - - reference 0..1 Mandatory String Literal reference, Relative, internal or absolute URL

Mapping for Procedures List Procedure

> Level 1 Procedure Resource > Level 2 CareConnect-Procedure-1 > Level 3 None
View Used FHIR Elements View All FHIR Elements
Name Card. Conformance Type Description, Constraints and mapping for Implementation
Procedure       An action that is being or was performed on a patient
Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources
Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative
Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
Constraint (pro-1): Reason not done is only permitted if notDone indicator is true
- id 0..1 Optional Id Logical id of this artifact
- meta 0..1 Required Meta Metadata about the resource
- - profile 1..1 Mandatory Uri Profiles this resource claims to conform to
The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Procedure-1'
- extension (anaestheticIssues) 0..1 Required Extension-CareConnect-AnaestheticIssues-1 Details of any adverse reaction to any anaesthetic agents
Constraint (ext-1): Must have either extensions or value[x], not both
Mapping to Digital Maternity data item = 'Specific anaesthaesia issues'
- identifier 0..* Required Identifier External Identifiers for this procedure
An identifier for this Procedure
- - system 1..1 Mandatory Uri The namespace for the identifier value The system from which the identifier came
- - value 1..1 Mandatory String The value that is unique A value for the identifier
- - assigner 0..1 Optional Reference Organization that issued id (may be just text)
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Optional CareConnect-Organization-1  
- - - reference 0..1 Optional String Literal reference, Relative, internal or absolute URL
- - - identifier 0..1 Optional Identifier Logical reference, when literal reference is not known
- - - display 0..1 Optional String Text alternative for the resource
- status 1..1 Mandatory Code preparation : in-progress : suspended : aborted : completed : entered-in-error : unknown
Binding (required): A code specifying the state of the procedure. EventStatus
- notDone 0..1 Optional Boolean True if procedure was not performed as scheduled
Default Value: false
- notDoneReason 0..1 Optional CodeableConcept Reason procedure was not performed
Binding (example): A code that identifies the reason a procedure was not performed. Procedure Not Performed Reason (SNOMED-CT)
- - coding 0..* Optional Coding Code defined by a terminology system
- - - system 0..1 Optional Uri Identity of the terminology system
- - - code 0..1 Optional Code Symbol in syntax defined by the system
- - - display 0..1 Optional String Representation defined by the system
- - - userSelected 0..1 Optional Boolean If this coding was chosen directly by the user
- - text 0..1 Optional String Plain text representation of the concept
- category 0..1 Optional CodeableConcept Classification of the procedure
Binding (example): A code that classifies a procedure for searching, sorting and display purposes. Procedure Category Codes (SNOMED CT)
- - coding 0..* Optional Coding Code defined by a terminology system
- - - system 0..1 Optional Uri Identity of the terminology system
- - - code 0..1 Optional Code Symbol in syntax defined by the system
- - - display 0..1 Optional String Representation defined by the system
- - - userSelected 0..1 Optional Boolean If this coding was chosen directly by the user
- - text 0..1 Optional String Plain text representation of the concept
- code 1..1 Mandatory CodeableConcept Identification of the procedure
Binding (preferred): A code to identify a specific procedure. Procedure Codes (SNOMED CT)
Mapping for Digital Maternity data item = 'Procedure'
- - coding (snomedCT) 1..1 Mandatory Coding Code defined by a terminology system
Binding (extensible): A code from the SNOMED Clinical Terminology UK. CareConnect-ProcedureCode-1
- - extension (snomedCTDescriptionID) 0..1 Optional Extension-coding-sctdescid The SNOMED CT Description ID for the display
Constraint (ext-1): Must have either extensions or value[x], not both
- - - system 1..1 Mandatory Uri Identity of the terminology system
The element MUST contain the value 'http://snomed.info/sct'
- - - code 1..1 Mandatory Code Symbol in syntax defined by the system
- - - display 1..1 Mandatory String Representation defined by the system
- - - userSelected 0..1 Optional Boolean If this coding was chosen directly by the user
- subject 1..1 Mandatory Reference Who the procedure was performed on
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Mandatory CareConnect-Patient-1  
- - reference 1..1 Mandatory String Literal reference, Relative, internal or absolute URL
- - identifier 0..1 Optional Identifier Logical reference, when literal reference is not known
- - display 0..1 Optional String Text alternative for the resource
- context 0..1 Optional Reference Encounter or episode associated with the procedure
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Optional EpisodeOfCare  
    Optional CareConnect-Encounter-1  
- - reference 0..1 Optional String Literal reference, Relative, internal or absolute URL
- - identifier 0..1 Optional Identifier Logical reference, when literal reference is not known
- - display 0..1 Optional String Text alternative for the resource
- performed[x] 1..1 Mandatory dateTime Date/Period the procedure was performed
Mapping for Digital Maternity data item = 'Date/time'
- performer 0..* Required BackboneElement The people who performed the procedure
- - role 0..1 Optional CodeableConcept The role the actor was in
Binding (example): A code that identifies the role of a performer of the procedure. Procedure Performer Role Codes
- - - coding 0..* Optional Coding Code defined by a terminology system
- - - - system 0..1 Optional Uri Identity of the terminology system
- - - - code 0..1 Optional Code Symbol in syntax defined by the system
- - - - display 0..1 Optional String Representation defined by the system
- - - - userSelected 0..1 Optional Boolean If this coding was chosen directly by the user
- - - text 0..1 Optional String Plain text representation of the concept
- - actor 1..1 Mandatory Reference The reference to the practitioner
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Optional Device  
    Optional CareConnect-Organization-1  
    Mandatory CareConnect-Practitioner-1  
- - - reference 1..1 Mandatory String Literal reference, Relative, internal or absolute URL
- - - identifier 0..1 Optional Identifier Logical reference, when literal reference is not known
- - - display 0..1 Optional String Text alternative for the resource
- - onBehalfOf 0..1 Required Reference Organization the device or practitioner was acting for
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Required CareConnect-Organization-1  
- - - reference 0..1 Required String Literal reference, Relative, internal or absolute URL
- - - identifier 0..1 Optional Identifier Logical reference, when literal reference is not known
- - - display 0..1 Optional String Text alternative for the resource
- bodySite 0..* Optional CodeableConcept Target body sites
Binding (example): Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures
Mapping for Digital Maternity data item = 'Anatomical site' and 'Laterality'
- - coding (snomedCT) 1..1 Mandatory Coding Code defined by a terminology system
Binding (extensible): A code from the SNOMED Clinical Terminology UK. CareConnect-BodySite-1
- - extension (snomedCTDescriptionID) 0..1 Optional Extension-coding-sctdescid The SNOMED CT Description ID for the display
Constraint (ext-1): Must have either extensions or value[x], not both
- - - system 1..1 Mandatory Uri Identity of the terminology system
The element MUST contain the value 'http://snomed.info/sct'
- - - code 1..1 Mandatory Code Symbol in syntax defined by the system
- - - display 1..1 Mandatory String Representation defined by the system
- - - userSelected 0..1 Optional Boolean If this coding was chosen directly by the user
- - text 0..1 Optional String Plain text representation of the concept
- complication 0..* Required CodeableConcept Complication following the procedure
Binding (example): Codes describing complications that resulted from a procedure. Condition/Problem/Diagnosis Codes
Mapping for Digital Maternity data item = 'Complications relating to procedure'
- - coding (snomedCT) 0..1 Required Coding Code defined by a terminology system
Binding (required): A code from the SNOMED Clinical Terminology UK. CareConnect-ConditionCode-1
- - extension (snomedCTDescriptionID) 0..1 Optional Extension-coding-sctdescid The SNOMED CT Description ID for the display
Constraint (ext-1): Must have either extensions or value[x], not both
- - - system 1..1 Mandatory Uri Identity of the terminology system
The element MUST contain the value 'http://snomed.info/sct'
- - - code 1..1 Mandatory Code Symbol in syntax defined by the system
- - - display 1..1 Mandatory String Representation defined by the system
- - - userSelected 0..1 Optional Boolean If this coding was chosen directly by the user
- - text 0..1 Optional String Plain text representation of the concept
- note 0..1 Optional Annotation Additional information about the procedure
Mapping for Digital Maternity data item = 'Comment'
- - author[x] 0..1 Optional Reference Individual responsible for the annotation
Constraint (ref-1): SHALL have a contained resource if a local reference is provided
    Optional RelatedPerson  
    Optional CareConnect-Patient-1  
    Optional CareConnect-Practitioner-1  
    Optional String  
- - time 0..1 Optional dateTime When the annotation was made
- - text 1..1 Mandatory String The annotation - text content

Mapping for Procedures list Organization

The Procedures list details has reference(s) to the Organization resource. This means that any exchange of the Procedures list details heading data must also include the Organization Details

Mapping for Procedures list Practitioner

The Procedures list details has reference(s) to the Practitioner resource. This means that any exchange of the Procedures list details heading data must also include the Practitioner Details

Mapping for Procedures list PractitionerRole

The Procedures list details has reference(s) to the Practitioner Role resource. This means that any exchange of the Procedures list details heading data must also include the Practitioner Role Details

Procedures list Example

Tags: fhir

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