US Veterans Health Administration FHIR Map Set Implementation Guide
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US Veterans Health Administration FHIR Map Set Implementation Guide - Downloaded Version 1.10.0 See the Directory of published versions

Resource Profile: Procedure: Radiology

Official URL: http://va.gov/fhir/StructureDefinition/ProcedureRadiology Version: 1.10.0
Active as of 2025-11-04 Computable Name: ProcedureRadiology

This StructureDefinition contains the maps for VistA file REGISTERED EXAMS (70.02) to us-core-procedure.

​See also the FHIR Shorthand.

Use Case Overview

Use Case: Procedure: Radiology«us-core-procedure»ProcedureRadiologysubjectencounterperformer.actorlocationPatientEncounterVisitPractitionerLocation

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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)
Constraints: us-core-7
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: RadiologyProcedureStatus FHIR (required): see mapping VF_RadiologyProcedureStatus
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... text SΣ 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
.... coding SΣ 0..* Coding Code defined by a terminology system
..... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: http://www.ama-assn.org/go/cpt
..... code SΣ 0..1 code Symbol in syntax defined by the system
..... display SΣ 0..1 string Representation defined by the system
... subject SΣC 1..1 Reference(Patient) Who the procedure was performed on
Constraints: pr-18-1510
... encounter SΣ 0..1 Reference(Encounter: Visit) 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
... performer Σ 0..* BackboneElement The people who performed the procedure
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor SΣ 1..1 Reference(Practitioner) The reference to the practitioner
... location SΣ 0..1 Reference(Location) Where the procedure happened

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required RadiologyProcedureStatus FHIR 📦1.10.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦7.0.0 US Core v7.0

Constraints

Id Grade Path(s) Description Expression
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()
pr-18-1510 best practice Procedure.subject If 70-2 > 70.02 then reference /Patient based on (70-.01) true
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
Binding: RadiologyProcedureStatus FHIR (required): see mapping VF_RadiologyProcedureStatus
... statusReason
.... text S 0..1 string Plain text representation of the concept
... category
.... text S 0..1 string Plain text representation of the concept
.... 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
... subject C 1..1 Reference(Patient) Who the procedure was performed on
Constraints: pr-18-1510
... encounter S 0..1 Reference(Encounter: Visit) 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) The reference to the practitioner
... location S 0..1 Reference(Location) Where the procedure happened

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.status Base required RadiologyProcedureStatus FHIR 📦1.10.0 This IG

Constraints

Id Grade Path(s) Description Expression
pr-18-1510 best practice Procedure.subject If 70-2 > 70.02 then reference /Patient based on (70-.01) true
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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)
Constraints: us-core-7
... 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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: RadiologyProcedureStatus FHIR (required): see mapping VF_RadiologyProcedureStatus
... 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.
.... 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
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... 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
.... text SΣ 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 Σ 0..1 string Plain text representation of the concept
... subject SΣC 1..1 Reference(Patient) Who the procedure was performed on
Constraints: pr-18-1510
... encounter SΣ 0..1 Reference(Encounter: Visit) 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) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location SΣ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
... 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
... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Procedure.status Base required RadiologyProcedureStatus FHIR 📦1.10.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦7.0.0 US Core v7.0
Procedure.performer.​function Base example Procedure Performer Role Codes 📦4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📦4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📦4.0.1 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📦4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
pr-18-1510 best practice Procedure.subject If 70-2 > 70.02 then reference /Patient based on (70-.01) true
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: 10 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

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

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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)
Constraints: us-core-7
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: RadiologyProcedureStatus FHIR (required): see mapping VF_RadiologyProcedureStatus
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... text SΣ 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
.... coding SΣ 0..* Coding Code defined by a terminology system
..... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: http://www.ama-assn.org/go/cpt
..... code SΣ 0..1 code Symbol in syntax defined by the system
..... display SΣ 0..1 string Representation defined by the system
... subject SΣC 1..1 Reference(Patient) Who the procedure was performed on
Constraints: pr-18-1510
... encounter SΣ 0..1 Reference(Encounter: Visit) 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
... performer Σ 0..* BackboneElement The people who performed the procedure
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor SΣ 1..1 Reference(Practitioner) The reference to the practitioner
... location SΣ 0..1 Reference(Location) Where the procedure happened

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required RadiologyProcedureStatus FHIR 📦1.10.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦7.0.0 US Core v7.0

Constraints

Id Grade Path(s) Description Expression
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()
pr-18-1510 best practice Procedure.subject If 70-2 > 70.02 then reference /Patient based on (70-.01) true
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
Binding: RadiologyProcedureStatus FHIR (required): see mapping VF_RadiologyProcedureStatus
... statusReason
.... text S 0..1 string Plain text representation of the concept
... category
.... text S 0..1 string Plain text representation of the concept
.... 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
... subject C 1..1 Reference(Patient) Who the procedure was performed on
Constraints: pr-18-1510
... encounter S 0..1 Reference(Encounter: Visit) 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) The reference to the practitioner
... location S 0..1 Reference(Location) Where the procedure happened

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.status Base required RadiologyProcedureStatus FHIR 📦1.10.0 This IG

Constraints

Id Grade Path(s) Description Expression
pr-18-1510 best practice Procedure.subject If 70-2 > 70.02 then reference /Patient based on (70-.01) true

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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)
Constraints: us-core-7
... 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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: RadiologyProcedureStatus FHIR (required): see mapping VF_RadiologyProcedureStatus
... 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.
.... 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
.... text SΣ 0..1 string Plain text representation of the concept
... category Σ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... 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
.... text SΣ 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 Σ 0..1 string Plain text representation of the concept
... subject SΣC 1..1 Reference(Patient) Who the procedure was performed on
Constraints: pr-18-1510
... encounter SΣ 0..1 Reference(Encounter: Visit) 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) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location SΣ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
... 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
... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Procedure.status Base required RadiologyProcedureStatus FHIR 📦1.10.0 This IG
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📦4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.code Base extensible US Core Procedure Codes 📦7.0.0 US Core v7.0
Procedure.performer.​function Base example Procedure Performer Role Codes 📦4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📦4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📦4.0.1 FHIR Std.
Procedure.outcome Base example Procedure Outcome Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📦4.0.1 FHIR Std.
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📦4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📦4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
pr-18-1510 best practice Procedure.subject If 70-2 > 70.02 then reference /Patient based on (70-.01) true
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: 10 elements

Structures

This structure refers to these other structures:

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