AU Base Implementation Guide
4.1.1-preview - Preview Australia flag

This page is part of the AU Base Implementation Guide 4.1.1-preview based on FHIR R4. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Base Procedure

Official URL: http://hl7.org.au/fhir/StructureDefinition/au-procedure Version: 4.1.1-preview
Standards status: Trial-use Maturity Level: 1 Computable Name: AUBaseProcedure

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile defines a procedure structure that localises core concepts, including terminology, for use in an Australian context. The purpose of this profile is to provide national level agreement on core localised concepts. This profile does not force conformance to core localised concepts. It enables implementers and modellers to make their own rules, i.e. profiling, about how to support these concepts for specific implementation needs.

Usage Notes

Profile specific implementation guidance:

  • The procedure-targetBodyStructure extension may be suitable for use where
    • the body site is not implicit in the code found in Procedure.code and
    • body site information is to be handled as a separate resource (e.g. to identify and track separately) instead of an inline coded element in Procedure.bodySite.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureA procedure in an Australian healthcare context
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... targetBodyStructure 0..*Reference(BodyStructure)The target point for this procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... code Σ0..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (preferred)
... subject Σ1..1Reference(Patient | Group)Who the procedure was performed on
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.statusrequiredEventStatus
Procedure.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureA procedure in an Australian healthcare context
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... targetBodyStructure 0..*Reference(BodyStructure)The target point for this procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code Σ0..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (preferred)
... subject Σ1..1Reference(Patient | Group)Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdGradePath(s)DetailsRequirements
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()

This structure is derived from Procedure

Summary

Extensions

This structure refers to these extensions:

Maturity: 1

Differential View

This structure is derived from Procedure

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureA procedure in an Australian healthcare context
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... targetBodyStructure 0..*Reference(BodyStructure)The target point for this procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... code Σ0..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (preferred)
... subject Σ1..1Reference(Patient | Group)Who the procedure was performed on
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.statusrequiredEventStatus
Procedure.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1

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()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureA procedure in an Australian healthcare context
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... targetBodyStructure 0..*Reference(BodyStructure)The target point for this procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code Σ0..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (preferred)
... subject Σ1..1Reference(Patient | Group)Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (preferred)
... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySitepreferredhttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdGradePath(s)DetailsRequirements
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()

This structure is derived from Procedure

Summary

Extensions

This structure refers to these extensions:

Maturity: 1

 

Other representations of profile: CSV, Excel, Schematron