MediRecords FHIR Implementation Guide
1.4.1 - release
| Defining URL: | https://fhir.medirecords.com/StructureDefinition/mr-procedure |
| Version: | 1.4.1 |
| Name: | MRProcedure |
| Title: | MR Procedure |
| Status: | Active as of 2024-10-28 02:34:31+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
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
Summary
Mandatory: 3 elements (1 nested mandatory element)
Must-Support: 23 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  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 |
| category | S | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (preferred) |
| 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 |
 performed[x] | 1..1 | dateTime | When the procedure was performed Slice: Unordered, Open by type:$this | |
 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) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| 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. | |||||
| Documentation for this format | ||||||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
| 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 |
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (preferred) |
| 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 |
| performed[x]:performedDateTime | Σ | 1..1 | dateTime | When the procedure was performed |
| 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) |
| Documentation for this format | ||||
This structure is derived from Procedure
Summary
Mandatory: 3 elements (1 nested mandatory element)
Must-Support: 23 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
| category | S | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (preferred) |
| 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 |
| performed[x] | 1..1 | dateTime | When the procedure was performed Slice: Unordered, Open by type:$this | |
| 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) |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| 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. | |||||
| Documentation for this format | ||||||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet / Code | URI | |||
| Procedure.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| Procedure.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tagsfrom the FHIR Standard | ||||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | preferred | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | preferred | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | ||||
| Procedure.performer.function | preferred | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.performer:assistant.function | example | Pattern: SNOMED CT code 22515006http://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.performer:anaesthetist.function | example | Pattern: SNOMED CT code 88189002http://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.performer:paediatrician.function | example | Pattern: SNOMED CT code 82296001http://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | preferred | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| 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() | |
| inv-mr-meta-security-01 | error | Procedure.meta.security | Medirecords supports only U, R security code : code.exists() implies (code = 'U' or code = 'R') | |
| inv-mr-procedure-status-01 | error | Procedure.status | Medirecords only supports 'completed' or 'entered-in-error' status : $this.exists() implies ($this = 'completed' or $this = 'entered-in-error') |