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ID

40056

Description

This is a complete version of the FHIR resource Procedure v4.0.0. FHIR version R4 (v4.0.0). FHIR is a platform specification that defines a set of capabilities use across the healthcare process, in all jurisdictions, and in lots of different context. https://www.hl7.org/fhir/resourcelist.html An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. This resource is used to record the details of current and historical procedures performed on or for a patient. A procedure is an activity that is performed on, with, or for a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise, etc. Procedures may be performed by a healthcare professional, a service provider, a friend or relative or in some cases by the patient themselves.

Link

https://www.hl7.org/fhir/resourcelist.html

Keywords

Versions (2)
  1. 3/10/20 3/10/20 -
  2. 3/10/20 3/10/20 -
Copyright Holder

HL7 FHIR

Uploaded on

March 10, 2020

DOI

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License

Creative Commons BY-NC 4.0
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    FHIR v4.0.0

    English

    Resource Procedure

    1 forms  
    1. StudyEvent: ODM
      1. Resource Procedure
    Procedure
    Description

    Procedure

    Alias
    UMLS CUI-1
    C0199171
    Business identifier assigned to this procedure
    Description

    Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0600091
    URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered by this procedure
    Description

    The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0162791
    UMLS CUI [1,3]
    C3272380
    UMLS CUI [2,1]
    C0199171
    UMLS CUI [2,2]
    C3272380
    UMLS CUI [2,3]
    C0442711
    UMLS CUI [3,1]
    C0199171
    UMLS CUI [3,2]
    C3272380
    UMLS CUI [3,3]
    C1704788
    URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to this procedure.
    Description

    The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0162791
    UMLS CUI [1,3]
    C3272380
    Resource that contains details of the request for this procedure
    Description

    A reference to a resource that contains details of the request for this procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0035201
    UMLS CUI [1,3]
    C1522508
    Event of which this procedure is a component
    Description

    A larger event of which this particular procedure is a component or step.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0449719
    UMLS CUI [1,3]
    C0205394
    UMLS CUI [1,4]
    C0441471
    Code to specify the state of procedure
    Description

    A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0449438
    UMLS CUI [1,3]
    C0805701
    Reason for the current state of the procedure
    Description

    Captures the reason for the current state of the procedure. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-not-performed-reason.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0449438
    UMLS CUI [1,3]
    C0566251
    Category of procedure
    Description

    A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-category.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0683312
    Code for specific procedure
    Description

    The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-code.html The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-category.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C2700391
    UMLS CUI [1,3]
    C0205369
    The person, animal or group on which the procedure was performed.
    Description

    The person, animal or group on which the procedure was performed.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1706203
    UMLS CUI [2,1]
    C0199171
    UMLS CUI [2,2]
    C1705428
    UMLS CUI [3,1]
    C0199171
    UMLS CUI [3,2]
    C0003062
    Encounter during which this procedure was created or performed
    Description

    The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1947978
    Time at which the procedure was performed
    Description

    Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

    Data type

    durationDatetime

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1442880
    Individual who recorded the record
    Description

    Individual who recorded the record and takes responsibility for its content.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0175636
    UMLS CUI [1,3]
    C0237401
    UMLS CUI [1,4]
    C0034869
    Individual who is making the procedure statement.
    Description

    Individual who is making the procedure statement.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0008961
    UMLS CUI [1,3]
    C1710187
    Location where the procedure happened
    Description

    The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0450429
    Code for reason why the procedure was performed
    Description

    The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-reason.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0805701
    UMLS CUI [1,3]
    C1272707
    Bodysite at which the procedure was performed
    Description

    Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-body-site.html

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1545955
    Outcome of the procedure
    Description

    The outcome of the procedure - did it resolve the reasons for the procedure being performed? The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-outcome.html

    Data type

    integer

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1274040
    Report of the procedure
    Description

    This could be a histology result, pathology report, surgical report, etc.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0684224
    Complications of the procedure
    Description

    Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-condition-code.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0009566
    Complications of the procedure
    Description

    Any complications that occurred during the procedure, or in the immediate post-performance period.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0009566
    UMLS CUI [1,3]
    C1522508
    Follow up of the procedure
    Description

    If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-procedure-followup.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1704685
    Notes about the procedure
    Description

    Any other notes and comments about the procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1317574
    Used reference for the procedure
    Description

    Identifies medications, devices and any other substance used as part of the procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1706462
    Coded items that were used during this procedure
    Description

    Identifies coded items that were used as part of the procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1547332
    Performer
    Description

    Performer

    Alias
    UMLS CUI-1
    C0199171
    UMLS CUI-2
    C1550480
    Performer of procedure
    Description

    Limited to "real" people rather than equipment.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1550480
    Function of the performer of the procedure
    Description

    Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-performer-role.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1550480
    UMLS CUI [1,3]
    C0542341
    Practitioner who was involved in the procedure
    Description

    Procedure.performer.actor

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1709627
    UMLS CUI [1,3]
    C1550480
    Organization the device or practitioner is working for
    Description

    The organization the device or practitioner was acting on behalf of.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C1709627
    UMLS CUI [1,3]
    C0029246
    UMLS CUI [2,1]
    C0199171
    UMLS CUI [2,2]
    C0699733
    UMLS CUI [2,3]
    C0029246
    Focal device
    Description

    Focal device

    Alias
    UMLS CUI-1
    C0199171
    UMLS CUI-2
    C0205234
    UMLS CUI-3
    C0025080
    Focal device which was part of the procedure
    Description

    A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0205234
    UMLS CUI [1,3]
    C0025080
    Change that happend to the focal device
    Description

    The kind of change that happened to the device during the procedure. The corresponding value set can be found at https://www.hl7.org/fhir/valueset-device-action.html

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C0205234
    UMLS CUI [1,3]
    C0025080
    UMLS CUI [1,4]
    C4319952
    Manipulated device
    Description

    The device that was manipulated (changed) during the procedure.

    Data type

    text

    Alias
    UMLS CUI [1,1]
    C0199171
    UMLS CUI [1,2]
    C4319952
    UMLS CUI [1,3]
    C0025080
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    Similar models

    Resource Procedure

    1 forms
    1. StudyEvent: ODM
      1. Resource Procedure
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Procedure
    C0199171 (UMLS CUI-1)
    Procedure.identifier
    Item
    Business identifier assigned to this procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0600091 (UMLS CUI [1,2])
    Procedure.instantiatesCanonical
    Item
    URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered by this procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0162791 (UMLS CUI [1,2])
    C3272380 (UMLS CUI [1,3])
    C0199171 (UMLS CUI [2,1])
    C3272380 (UMLS CUI [2,2])
    C0442711 (UMLS CUI [2,3])
    C0199171 (UMLS CUI [3,1])
    C3272380 (UMLS CUI [3,2])
    C1704788 (UMLS CUI [3,3])
    Procedure.instantiatesUri
    Item
    URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to this procedure.
    text
    C0199171 (UMLS CUI [1,1])
    C0162791 (UMLS CUI [1,2])
    C3272380 (UMLS CUI [1,3])
    Procedure.basedOn
    Item
    Resource that contains details of the request for this procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0035201 (UMLS CUI [1,2])
    C1522508 (UMLS CUI [1,3])
    Procedure.partOf
    Item
    Event of which this procedure is a component
    text
    C0199171 (UMLS CUI [1,1])
    C0449719 (UMLS CUI [1,2])
    C0205394 (UMLS CUI [1,3])
    C0441471 (UMLS CUI [1,4])
    Item
    Code to specify the state of procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0449438 (UMLS CUI [1,2])
    C0805701 (UMLS CUI [1,3])
    Procedure.status
    Code List
    Code to specify the state of procedure
    CL Item
    Preparation  (preparation)
    The core event has not started yet, but some staging activities have begun (e.g. surgical suite preparation). Preparation stages may be tracked for billing purposes. (Comment:en)
    CL Item
    In Progress  (in-progress)
    The event is currently occurring. (Comment:en)
    CL Item
    Not done (not-done)
    The event was terminated prior to any activity beyond preparation. I.e. The 'main' activity has not yet begun. The boundary between preparatory and the 'main' activity is context-specific. (Comment:en)
    CL Item
    On Hold  (on-hold )
    The event has been temporarily stopped but is expected to resume in the future. (Comment:en)
    CL Item
    Stopped  (stopped)
    The event was terminated prior to the full completion of the intended activity but after at least some of the 'main' activity (beyond preparation) has occurred. (Comment:en)
    CL Item
    Completed  (completed)
    The event has now concluded. (Comment:en)
    CL Item
    Entered in Error  (entered-in-error)
    This electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".). (Comment:en)
    CL Item
    Unknown  (unknown)
    The authoring/source system does not know which of the status values currently applies for this event. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which. (Comment:en)
    Item
    Reason for the current state of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0449438 (UMLS CUI [1,2])
    C0566251 (UMLS CUI [1,3])
    Procedure.status
    Code List
    Reason for the current state of the procedure
    Procedure.category
    Item
    Category of procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0683312 (UMLS CUI [1,2])
    Procedure.code
    Item
    Code for specific procedure
    text
    C0199171 (UMLS CUI [1,1])
    C2700391 (UMLS CUI [1,2])
    C0205369 (UMLS CUI [1,3])
    Procedure.subject
    Item
    The person, animal or group on which the procedure was performed.
    text
    C0199171 (UMLS CUI [1,1])
    C1706203 (UMLS CUI [1,2])
    C0199171 (UMLS CUI [2,1])
    C1705428 (UMLS CUI [2,2])
    C0199171 (UMLS CUI [3,1])
    C0003062 (UMLS CUI [3,2])
    Procedure.encounter
    Item
    Encounter during which this procedure was created or performed
    text
    C0199171 (UMLS CUI [1,1])
    C1947978 (UMLS CUI [1,2])
    Procedure.performed[x]
    Item
    Time at which the procedure was performed
    durationDatetime
    C0199171 (UMLS CUI [1,1])
    C1442880 (UMLS CUI [1,2])
    Procedure.recorder
    Item
    Individual who recorded the record
    text
    C0199171 (UMLS CUI [1,1])
    C0175636 (UMLS CUI [1,2])
    C0237401 (UMLS CUI [1,3])
    C0034869 (UMLS CUI [1,4])
    Procedure.asserter
    Item
    Individual who is making the procedure statement.
    text
    C0199171 (UMLS CUI [1,1])
    C0008961 (UMLS CUI [1,2])
    C1710187 (UMLS CUI [1,3])
    Procedure.location
    Item
    Location where the procedure happened
    text
    C0199171 (UMLS CUI [1,1])
    C0450429 (UMLS CUI [1,2])
    Procedure.reasonCode
    Item
    Code for reason why the procedure was performed
    text
    C0199171 (UMLS CUI [1,1])
    C0805701 (UMLS CUI [1,2])
    C1272707 (UMLS CUI [1,3])
    Procedure.bodySite
    Item
    Bodysite at which the procedure was performed
    integer
    C0199171 (UMLS CUI [1,1])
    C1545955 (UMLS CUI [1,2])
    Procedure.outcome
    Item
    Outcome of the procedure
    integer
    C0199171 (UMLS CUI [1,1])
    C1274040 (UMLS CUI [1,2])
    Procedure.report
    Item
    Report of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0684224 (UMLS CUI [1,2])
    Procedure.complication
    Item
    Complications of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0009566 (UMLS CUI [1,2])
    Procedure.complicationDetail
    Item
    Complications of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0009566 (UMLS CUI [1,2])
    C1522508 (UMLS CUI [1,3])
    Procedure.followUp
    Item
    Follow up of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1704685 (UMLS CUI [1,2])
    Procedure.note
    Item
    Notes about the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1317574 (UMLS CUI [1,2])
    Procedure.usedReference
    Item
    Used reference for the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1706462 (UMLS CUI [1,2])
    Procedure.usedCode
    Item
    Coded items that were used during this procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1547332 (UMLS CUI [1,2])
    Item Group
    Performer
    C0199171 (UMLS CUI-1)
    C1550480 (UMLS CUI-2)
    Procedure.performer
    Item
    Performer of procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1550480 (UMLS CUI [1,2])
    Procedure.performer.function
    Item
    Function of the performer of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1550480 (UMLS CUI [1,2])
    C0542341 (UMLS CUI [1,3])
    Procedure.performer.actor
    Item
    Practitioner who was involved in the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C1709627 (UMLS CUI [1,2])
    C1550480 (UMLS CUI [1,3])
    Procedure.performer.onBehalfOf
    Item
    Organization the device or practitioner is working for
    text
    C0199171 (UMLS CUI [1,1])
    C1709627 (UMLS CUI [1,2])
    C0029246 (UMLS CUI [1,3])
    C0199171 (UMLS CUI [2,1])
    C0699733 (UMLS CUI [2,2])
    C0029246 (UMLS CUI [2,3])
    Item Group
    Focal device
    C0199171 (UMLS CUI-1)
    C0205234 (UMLS CUI-2)
    C0025080 (UMLS CUI-3)
    Procedure.focalDevice
    Item
    Focal device which was part of the procedure
    text
    C0199171 (UMLS CUI [1,1])
    C0205234 (UMLS CUI [1,2])
    C0025080 (UMLS CUI [1,3])
    Procedure.focalDevice.action
    Item
    Change that happend to the focal device
    text
    C0199171 (UMLS CUI [1,1])
    C0205234 (UMLS CUI [1,2])
    C0025080 (UMLS CUI [1,3])
    C4319952 (UMLS CUI [1,4])
    Procedure.focalDevice.manipulated
    Item
    Manipulated device
    text
    C0199171 (UMLS CUI [1,1])
    C4319952 (UMLS CUI [1,2])
    C0025080 (UMLS CUI [1,3])
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