MediRecords FHIR Implementation Guide
1.4.1 - release


Resource Profile: MR Procedure

Defining URL:https://fhir.medirecords.com/StructureDefinition/mr-procedure
Version:1.4.1
Name:MRProcedure
Title:MR Procedure
Status:Active as of 2025-02-03 04:29:41+0000
Definition:

MediRecords Procedure profile to record details of procedure performed for the patient in context.

Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

https://fhir.medirecords.com/StructureDefinition/mr-procedure

Formal Views of Profile Content

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

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta 0..1 MRMeta Metadata about a resource
.... lastUpdated S 0..1 instant When the resource version last changed
.... security S 0..* Coding Security Labels applied to this resource
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... procedure-technique S 0..1 CodeableConcept The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
... status SC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
inv-mr-procedure-status-01: Medirecords only supports 'completed' or 'entered-in-error' status
... code S 1..1 CodeableConcept Identification of the procedure
Binding: Procedure . (preferred)
... subject S 1..1 Reference(MR Patient) Who the procedure was performed on
... encounter S 0..1 Reference(MR Encounter) Encounter created as part of
... Slices for performed[x] 1..1 dateTime When the procedure was performed
Slice: Unordered, Open by type:$this
.... performed[x]:performedDateTime S 1..1 dateTime When the procedure was performed
... Slices for performer 0..* BackboneElement The people who performed the procedure
Slice: Unordered, Open by pattern:function
.... performer:All Slices Content/Rules for all slices
..... function 1..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (preferred)
.... performer:assistant S 0..1 BackboneElement The people who performed the procedure
..... function S 0..1 CodeableConcept Type of performance
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: 22515006
..... actor S 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:anaesthetist S 0..1 BackboneElement The people who performed the procedure
..... function S 0..1 CodeableConcept Type of performance
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: 88189002
..... actor S 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:paediatrician S 0..1 BackboneElement The people who performed the procedure
..... function S 0..1 CodeableConcept Type of performance
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: 82296001
..... actor S 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
... reasonReference S 0..* Reference(MR Condition | AU Base Diagnostic Report | MR Procedure | Observation | DocumentReference) The justification that the procedure was performed
... bodySite S 0..* CodeableConcept Target body sites
Binding: Body Site . (preferred)
... report S 0..* Reference(AU Base Diagnostic Report) A contained reference is encouraged to represent the diagnostic report
... complicationDetail S 0..* Reference(MR Condition) A contained reference is encouraged to represent the post operation complications
... note
.... text S 1..1 markdown The annotation - text content (as markdown)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... id Σ 0..1 id Logical id of this artifact
... meta 0..1 MRMeta Metadata about a resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security SΣC 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


inv-mr-meta-security-01: Medirecords supports only U, R security code
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... 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
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... procedure-technique S 0..1 CodeableConcept The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
... 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): A code specifying the state of the procedure.


inv-mr-procedure-status-01: Medirecords only supports 'completed' or 'entered-in-error' status
... 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) (preferred)
... code SΣ 1..1 CodeableConcept Identification of the procedure
Binding: Procedure . (preferred)
... subject SΣ 1..1 Reference(MR Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(MR Encounter) Encounter created as part of
... Slices for performed[x] Σ 1..1 dateTime When the procedure was performed
Slice: Unordered, Closed by type:$this
.... performed[x]:performedDateTime SΣ 1..1 dateTime 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
... Slices for performer Σ 0..* BackboneElement The people who performed the procedure
Slice: Unordered, Open by pattern:function
.... performer:All Slices Content/Rules for all slices
..... 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 1..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (preferred)
..... actor Σ 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
.... performer:assistant SΣ 0..1 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 SΣ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.


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: 22515006
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... actor SΣ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:anaesthetist SΣ 0..1 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 SΣ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.


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: 88189002
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... actor SΣ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:paediatrician SΣ 0..1 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 SΣ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.


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: 82296001
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... actor SΣ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
... location Σ 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 SΣ 0..* Reference(MR Condition | AU Base Diagnostic Report | MR Procedure | Observation | DocumentReference) The justification that the procedure was performed
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: Body Site . (preferred)
... 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 S 0..* Reference(AU Base Diagnostic Report) A contained reference is encouraged to represent the diagnostic report
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail S 0..* Reference(MR Condition) A contained reference is encouraged to represent the post operation complications
... 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.



doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta 0..1 MRMeta Metadata about a resource
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... security ΣC 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


inv-mr-meta-security-01: Medirecords supports only U, R security code
... Slices for extension Content/Rules for all slices
.... procedure-technique 0..1 CodeableConcept The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
... status ?!ΣC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.


inv-mr-procedure-status-01: Medirecords only supports 'completed' or 'entered-in-error' status
... code Σ 1..1 CodeableConcept Identification of the procedure
Binding: Procedure . (preferred)
... subject Σ 1..1 Reference(MR Patient) Who the procedure was performed on
... encounter Σ 0..1 Reference(MR Encounter) Encounter created as part of
... Slices for performed[x] Content/Rules for all slices
.... performed[x]:performedDateTime Σ 1..1 dateTime When the procedure was performed
... Slices for performer Content/Rules for all slices
.... performer:assistant Σ 0..1 BackboneElement The people who performed the procedure
..... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer 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: 22515006
..... actor Σ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
.... performer:anaesthetist Σ 0..1 BackboneElement The people who performed the procedure
..... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer 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: 88189002
..... actor Σ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
.... performer:paediatrician Σ 0..1 BackboneElement The people who performed the procedure
..... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer 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: 82296001
..... actor Σ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
... reasonReference Σ 0..* Reference(MR Condition | AU Base Diagnostic Report | MR Procedure | Observation | DocumentReference) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: Body Site . (preferred)
... report 0..* Reference(AU Base Diagnostic Report) A contained reference is encouraged to represent the diagnostic report
... complicationDetail 0..* Reference(MR Condition) A contained reference is encouraged to represent the post operation complications
... note 0..* Annotation Additional information about the procedure
.... text Σ 1..1 markdown The annotation - text content (as markdown)

doco Documentation for this format

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta 0..1 MRMeta Metadata about a resource
.... lastUpdated S 0..1 instant When the resource version last changed
.... security S 0..* Coding Security Labels applied to this resource
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... procedure-technique S 0..1 CodeableConcept The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
... status SC 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
inv-mr-procedure-status-01: Medirecords only supports 'completed' or 'entered-in-error' status
... code S 1..1 CodeableConcept Identification of the procedure
Binding: Procedure . (preferred)
... subject S 1..1 Reference(MR Patient) Who the procedure was performed on
... encounter S 0..1 Reference(MR Encounter) Encounter created as part of
... Slices for performed[x] 1..1 dateTime When the procedure was performed
Slice: Unordered, Open by type:$this
.... performed[x]:performedDateTime S 1..1 dateTime When the procedure was performed
... Slices for performer 0..* BackboneElement The people who performed the procedure
Slice: Unordered, Open by pattern:function
.... performer:All Slices Content/Rules for all slices
..... function 1..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (preferred)
.... performer:assistant S 0..1 BackboneElement The people who performed the procedure
..... function S 0..1 CodeableConcept Type of performance
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: 22515006
..... actor S 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:anaesthetist S 0..1 BackboneElement The people who performed the procedure
..... function S 0..1 CodeableConcept Type of performance
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: 88189002
..... actor S 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:paediatrician S 0..1 BackboneElement The people who performed the procedure
..... function S 0..1 CodeableConcept Type of performance
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: 82296001
..... actor S 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
... reasonReference S 0..* Reference(MR Condition | AU Base Diagnostic Report | MR Procedure | Observation | DocumentReference) The justification that the procedure was performed
... bodySite S 0..* CodeableConcept Target body sites
Binding: Body Site . (preferred)
... report S 0..* Reference(AU Base Diagnostic Report) A contained reference is encouraged to represent the diagnostic report
... complicationDetail S 0..* Reference(MR Condition) A contained reference is encouraged to represent the post operation complications
... note
.... text S 1..1 markdown The annotation - text content (as markdown)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... id Σ 0..1 id Logical id of this artifact
... meta 0..1 MRMeta Metadata about a resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security SΣC 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


inv-mr-meta-security-01: Medirecords supports only U, R security code
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... 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
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... procedure-technique S 0..1 CodeableConcept The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
... 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): A code specifying the state of the procedure.


inv-mr-procedure-status-01: Medirecords only supports 'completed' or 'entered-in-error' status
... 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) (preferred)
... code SΣ 1..1 CodeableConcept Identification of the procedure
Binding: Procedure . (preferred)
... subject SΣ 1..1 Reference(MR Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(MR Encounter) Encounter created as part of
... Slices for performed[x] Σ 1..1 dateTime When the procedure was performed
Slice: Unordered, Closed by type:$this
.... performed[x]:performedDateTime SΣ 1..1 dateTime 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
... Slices for performer Σ 0..* BackboneElement The people who performed the procedure
Slice: Unordered, Open by pattern:function
.... performer:All Slices Content/Rules for all slices
..... 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 1..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (preferred)
..... actor Σ 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
.... performer:assistant SΣ 0..1 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 SΣ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.


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: 22515006
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... actor SΣ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:anaesthetist SΣ 0..1 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 SΣ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.


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: 88189002
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... actor SΣ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
.... performer:paediatrician SΣ 0..1 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 SΣ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.


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: 82296001
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
..... actor SΣ 1..1 Reference(MR PractitionerRole | MR Practitioner | MR Patient) The reference to the practitioner
..... onBehalfOf 0..1 Reference(MR Organisation) Organization the device or practitioner was acting for
... location Σ 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 SΣ 0..* Reference(MR Condition | AU Base Diagnostic Report | MR Procedure | Observation | DocumentReference) The justification that the procedure was performed
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: Body Site . (preferred)
... 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 S 0..* Reference(AU Base Diagnostic Report) A contained reference is encouraged to represent the diagnostic report
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail S 0..* Reference(MR Condition) A contained reference is encouraged to represent the post operation complications
... 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.



doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / CodeURI
Procedure.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
Procedure.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
Procedure.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categorypreferredProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codepreferredProcedure .
https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.performer.functionpreferredProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.performer:assistant.functionexamplePattern: SNOMED-CT Code 22515006
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.performer:anaesthetist.functionexamplePattern: SNOMED-CT Code 88189002
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.performer:paediatrician.functionexamplePattern: SNOMED-CT Code 82296001
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySitepreferredBodySite .
https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
inv-mr-meta-security-01errorProcedure.meta.securityMedirecords supports only U, R security code
: code.exists() implies (code = 'U' or code = 'R')
inv-mr-procedure-status-01errorProcedure.statusMedirecords only supports 'completed' or 'entered-in-error' status
: $this.exists() implies ($this = 'completed' or $this = 'entered-in-error')