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Resource Profile: Procedure: Outpatient

This StructureDefinition contains the maps for VistA file V CPT (9000010.18) to us-core-procedure.

Usage:

• CapabilityStatements using this Resource Profile: Lighthouse Patient Health API
• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile(5.0.1)	An action that is being or was performed on a patient This profile also complies with the profiles US Core Procedure Profile (6.1.0) and US Core Procedure Profile (7.0.0) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) ele-1: All FHIR elements must have a @value or children Required Pattern: completed
category	SΣ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 371883000
display		1..1	string	Representation defined by the system Fixed Value: Outpatient procedure (procedure)
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure ele-1: All FHIR elements must have a @value or children
coding	SΣ	0..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	SΣ	0..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children Required Pattern: http://www.ama-assn.org/go/cpt
code	SΣ	0..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
display	SΣ	0..1	string	Representation defined by the system ele-1: All FHIR elements must have a @value or children
text	SΣ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
encounter	SΣ	0..1	Reference(Encounter: Outpatient)	Encounter created as part of ele-1: All FHIR elements must have a @value or children
Slices for performed[x]	SΣC	0..1		When the procedure was performed Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performed[x]:performedDateTime	SΣC	0..1	dateTime	When the procedure was performed ele-1: All FHIR elements must have a @value or children
performer	Σ	0..*	BackboneElement	The people who performed the procedure ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
actor	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner ele-1: All FHIR elements must have a @value or children
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. ele-1: All FHIR elements must have a @value or children
coding	Σ	0..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	SΣ	0..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children Required Pattern: urn:see-termmap-in-mapParameter
code	SΣ	0..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
note		0..*	Annotation	Additional information about the procedure ele-1: All FHIR elements must have a @value or children
text	SΣ	1..1	markdown	The annotation - text content (as markdown) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.status	required	Pattern: completed http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 371883000("Outpatient procedure (procedure)") http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	USCoreProcedureCodes http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	USCoreProcedureProfile(5.0.1)	An action that is being or was performed on a patient This profile also complies with the profiles US Core Procedure Profile (6.1.0) and US Core Procedure Profile (7.0.0)
status		1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Required Pattern: completed
category	S	0..1	CodeableConcept	Classification of the procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 371883000
display		1..1	string	Representation defined by the system Fixed Value: Outpatient procedure (procedure)
code
coding	S	0..*	Coding	Code defined by a terminology system
system	S	0..1	uri	Identity of the terminology system Required Pattern: http://www.ama-assn.org/go/cpt
code	S	0..1	code	Symbol in syntax defined by the system
display	S	0..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
subject		1..1	Reference(Patient)	Who the procedure was performed on
encounter	S	0..1	Reference(Encounter: Outpatient)	Encounter created as part of
Slices for performed[x]		0..1	dateTime, Period, string, Age, Range	When the procedure was performed Slice: Unordered, Open by type:$this
performed[x]:performedDateTime	S	0..1	dateTime S	When the procedure was performed
performer
actor	S	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed
coding
system	S	0..1	uri	Identity of the terminology system Required Pattern: urn:see-termmap-in-mapParameter
code	S	0..1	code	Symbol in syntax defined by the system
note
text	S	1..1	markdown	The annotation - text content (as markdown)
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile(5.0.1)	An action that is being or was performed on a patient This profile also complies with the profiles US Core Procedure Profile (6.1.0) and US Core Procedure Profile (7.0.0) us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Required Pattern: completed
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	SΣ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 371883000
display		1..1	string	Representation defined by the system Fixed Value: Outpatient procedure (procedure)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	0..1	uri	Identity of the terminology system Required Pattern: http://www.ama-assn.org/go/cpt
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Symbol in syntax defined by the system
display	SΣ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(Patient)	Who the procedure was performed on
encounter	SΣ	0..1	Reference(Encounter: Outpatient)	Encounter created as part of
Slices for performed[x]	SΣC	0..1		When the procedure was performed Slice: Unordered, Open by type:$this
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
performed[x]:performedDateTime	SΣC	0..1	dateTime S	When the procedure was performed
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	0..1	uri	Identity of the terminology system Required Pattern: urn:see-termmap-in-mapParameter
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	SΣ	1..1	markdown	The annotation - text content (as markdown)
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
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 Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	Pattern: completed http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 371883000("Outpatient procedure (procedure)") http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	USCoreProcedureCodes http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from USCoreProcedureProfile

Summary

Must-Support: 13 elements

Structures

This structure refers to these other structures:

• Patient (http://va.gov/fhir/StructureDefinition/Patient)
• Encounter: Outpatient (http://va.gov/fhir/StructureDefinition/EncounterOutpatient)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Procedure.performed[x]

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile(5.0.1)	An action that is being or was performed on a patient This profile also complies with the profiles US Core Procedure Profile (6.1.0) and US Core Procedure Profile (7.0.0) dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) ele-1: All FHIR elements must have a @value or children Required Pattern: completed
category	SΣ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 371883000
display		1..1	string	Representation defined by the system Fixed Value: Outpatient procedure (procedure)
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure ele-1: All FHIR elements must have a @value or children
coding	SΣ	0..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	SΣ	0..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children Required Pattern: http://www.ama-assn.org/go/cpt
code	SΣ	0..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
display	SΣ	0..1	string	Representation defined by the system ele-1: All FHIR elements must have a @value or children
text	SΣ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
encounter	SΣ	0..1	Reference(Encounter: Outpatient)	Encounter created as part of ele-1: All FHIR elements must have a @value or children
Slices for performed[x]	SΣC	0..1		When the procedure was performed Slice: Unordered, Open by type:$this ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performed[x]:performedDateTime	SΣC	0..1	dateTime	When the procedure was performed ele-1: All FHIR elements must have a @value or children
performer	Σ	0..*	BackboneElement	The people who performed the procedure ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
actor	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner ele-1: All FHIR elements must have a @value or children
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. ele-1: All FHIR elements must have a @value or children
coding	Σ	0..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	SΣ	0..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children Required Pattern: urn:see-termmap-in-mapParameter
code	SΣ	0..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
note		0..*	Annotation	Additional information about the procedure ele-1: All FHIR elements must have a @value or children
text	SΣ	1..1	markdown	The annotation - text content (as markdown) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.status	required	Pattern: completed http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 371883000("Outpatient procedure (procedure)") http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	USCoreProcedureCodes http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

Differential View

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	USCoreProcedureProfile(5.0.1)	An action that is being or was performed on a patient This profile also complies with the profiles US Core Procedure Profile (6.1.0) and US Core Procedure Profile (7.0.0)
status		1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Required Pattern: completed
category	S	0..1	CodeableConcept	Classification of the procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 371883000
display		1..1	string	Representation defined by the system Fixed Value: Outpatient procedure (procedure)
code
coding	S	0..*	Coding	Code defined by a terminology system
system	S	0..1	uri	Identity of the terminology system Required Pattern: http://www.ama-assn.org/go/cpt
code	S	0..1	code	Symbol in syntax defined by the system
display	S	0..1	string	Representation defined by the system
text	S	0..1	string	Plain text representation of the concept
subject		1..1	Reference(Patient)	Who the procedure was performed on
encounter	S	0..1	Reference(Encounter: Outpatient)	Encounter created as part of
Slices for performed[x]		0..1	dateTime, Period, string, Age, Range	When the procedure was performed Slice: Unordered, Open by type:$this
performed[x]:performedDateTime	S	0..1	dateTime S	When the procedure was performed
performer
actor	S	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed
coding
system	S	0..1	uri	Identity of the terminology system Required Pattern: urn:see-termmap-in-mapParameter
code	S	0..1	code	Symbol in syntax defined by the system
note
text	S	1..1	markdown	The annotation - text content (as markdown)
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile(5.0.1)	An action that is being or was performed on a patient This profile also complies with the profiles US Core Procedure Profile (6.1.0) and US Core Procedure Profile (7.0.0) us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress'
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) Required Pattern: completed
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	SΣ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 371883000
display		1..1	string	Representation defined by the system Fixed Value: Outpatient procedure (procedure)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	0..1	uri	Identity of the terminology system Required Pattern: http://www.ama-assn.org/go/cpt
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Symbol in syntax defined by the system
display	SΣ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(Patient)	Who the procedure was performed on
encounter	SΣ	0..1	Reference(Encounter: Outpatient)	Encounter created as part of
Slices for performed[x]	SΣC	0..1		When the procedure was performed Slice: Unordered, Open by type:$this
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
performed[x]:performedDateTime	SΣC	0..1	dateTime S	When the procedure was performed
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	0..1	uri	Identity of the terminology system Required Pattern: urn:see-termmap-in-mapParameter
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	SΣ	1..1	markdown	The annotation - text content (as markdown)
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
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 Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	Pattern: completed http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 371883000("Outpatient procedure (procedure)") http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	USCoreProcedureCodes http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-7	error	Procedure	Performed SHALL be present if the status is 'completed' or 'in-progress' : (status='completed' or status='in-progress') implies performed.exists()

This structure is derived from USCoreProcedureProfile

Summary

Must-Support: 13 elements

Structures

This structure refers to these other structures:

• Patient (http://va.gov/fhir/StructureDefinition/Patient)
• Encounter: Outpatient (http://va.gov/fhir/StructureDefinition/EncounterOutpatient)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Procedure.performed[x]

Other representations of profile: CSV, Excel, Schematron