Procedure List

Constructing a procedure list

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model which use the Procedure Resource. The Procedure Resource is referenced via the List Resource.

Resources Used for Profile Design

The FHIR Resources are profiled to create the procedure list as follows:

CareConnect-ITK-Procedure-List-1 - A CareConnect derived NHS Digital Profile for recording a snapshot of the list of Procedures for the patient.
CareConnect-ITK-Procedure-1 - A CareConnect derived NHS Digital Profile for procedures. The Procedure Resource is used to record an action that is or was performed on a patient.

List

This Resource acts as a container for the procedures. The following is an example of the main elements used:

identifier - uniquely identifies this list of procedures (UUIDs)
code - the type of list (for example SNOMED CT concept for “requested procedures”)
status - should always be “current”
mode - should always be “snapshot”
subject - a reference to the patient whose procedure list this is
Encounter - a reference to the context in which the list was created (the inpatient stay for example)
date - when the list was prepared
source - who or what defined the list
entry - a reference to the Procedure Resource entry

Procedure

This Resource is used to record detailed information about a procedure. The following is an example of the elements that can be used:

identifier - uniquely identifies this procedure (UUIDs)
status - completed, aborted etc
category - Classification of the procedure
code - identification of the procedure
bodySite - the body site of the procedure
complicationDetail - details of any intra-operative complications encountered during the procedure, arising during the patient’s stay in the recovery unit or directly attributable to the procedure
anestheticIssues - details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc.
note - any further textual comment to clarify such as statement that information is partial or incomplete
performed - when procedure was performed
subject - the patient
outcome - the result of procedure

Procedure.code

71388002 | Procedure (procedure) | hierarcy AND Procedure with explicit context (situation)

SCTID: 129125009 [EXTENSIBLE]

Terminology binding as a SNOMED Expression:

<<71388002 |Procedure|

<<129125009 |Procedure with explicit context|

Procedure.code can carry combined bodySite expression:

Procedure.bodySite

<<442083009 |anatomical or acquired body structure|

Note: that this includes the following two sub-hierarchies

91723000 anatomical structure
280115004 acquired body structure

So, an alternative is only:

91723000 anatomical structure

Procedure.complication

References the condition resource.

Procedure.anestheticIssues

Uses the Extension-CareConnect-AnaestheticIssues-1 extension to either references the condition resource or carry a SNOMED CT concept to detail the anaesthetic issues the patient had.

Procedure.note

Any further textual comment to clarify such as statement that information is partial or incomplete. MUST be repeated in the FHIR element Composition.section.text.

How the Procedure List is Constructed

The Procedure list is constructed as a single list. The diagram below shows the Resources used and relationships between the Resources.

Procedure List Item Example

Example to show a procedure list

Procedure List

Note: These examples have not been clinically assured against Digital Medicines use cases.
Examples are illustrative only.

Procedure Example