ID

40056

Beschreibung

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

Stichworte

Versionen (2)
  1. 10.03.20 10.03.20 -
  2. 10.03.20 10.03.20 -
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HL7 FHIR

Hochgeladen am

10. März 2020

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Lizenz

Creative Commons BY-NC 4.0
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FHIR v4.0.0

Englisch

Resource Procedure

1 Formulare  
  1. StudyEvent: ODM
    1. Resource Procedure
Procedure
Beschreibung

Procedure

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

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.

Datentyp

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
Beschreibung

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.

Datentyp

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.
Beschreibung

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.

Datentyp

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
Beschreibung

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

Datentyp

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
Beschreibung

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

Datentyp

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
Beschreibung

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

Datentyp

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
Beschreibung

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

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.
Beschreibung

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

Datentyp

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
Beschreibung

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

Datentyp

text

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

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.

Datentyp

durationDatetime

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

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

Datentyp

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.
Beschreibung

Individual who is making the procedure statement.

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

integer

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

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

Datentyp

integer

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

Any other notes and comments about the procedure.

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

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

Performer

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

Limited to "real" people rather than equipment.

Datentyp

text

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

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

Datentyp

text

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

Procedure.performer.actor

Datentyp

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
Beschreibung

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

Datentyp

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
Beschreibung

Focal device

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

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.

Datentyp

text

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

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

Datentyp

text

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

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

Datentyp

text

Alias
UMLS CUI [1,1]
C0199171
UMLS CUI [1,2]
C4319952
UMLS CUI [1,3]
C0025080
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Ähnliche Modelle

Resource Procedure

1 Formulare
  1. StudyEvent: ODM
    1. Resource Procedure
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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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