AU Core Implementation Guide
0.3.0-ballot - R1
AU Core Implementation Guide
0.3.0-ballot - R1
This page is part of the AU Core (v0.3.0-ballot: AU Core R1 Ballot 5) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions
| Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-procedure | Version: 0.3.0-ballot | |||
| Standards status: Draft | Maturity Level: 0 | Computable Name: AUCoreProcedure | ||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved. |
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This profile sets minimum expectations for a Procedure resource to record, search, and fetch procedures associated with a patient. It is based on the AU Base Procedure profile and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the Procedure resource when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.
The following are supported usage scenarios for this profile:
A resource conforming to this profile is conformant to:
No equivalent International Patient Access profile.
Conformance in reverse is not guaranteed, i.e. a resource conforming to International Patient Summary, or US Core MAY NOT conform to AU Core.
Procedure.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.Procedure.code.text and/or Procedure.code.coding.display so that client applications can at least display the condition even if the client application does not recognise the code supplied.Procedure.status is “completed”Procedure.reasonCode, or a reference with Procedure.reasonReference to a Condition or other resource.
Procedure.focalDevice with a reference to a Device resourceUsage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from AUBaseProcedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 0..* | AUBaseProcedure | A procedure in an Australian healthcare context | |
  status | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
| statusReason | S | 0..1 | CodeableConcept | Reason for current status |
| category | S | 0..1 | CodeableConcept | Classification of the procedure |
| code | S | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedure  (extensible) |
 subject | S | 1..1 | Reference(AU Core Patient) | Who the procedure was performed on |
| encounter | S | 0..1 | Reference(AU Core Encounter) | Encounter created as part of |
| performed[x] | S | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed |
| recorder | S | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Who recorded the procedure |
| asserter | S | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Person who asserts this procedure |
| reasonCode | S | 0..* | CodeableConcept | Coded reason procedure performed |
| reasonReference | S | 0..* | Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) | The justification that the procedure was performed |
| bodySite | SC | 0..* | CodeableConcept | Target body sites Binding: Body Site (extensible)au-core-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT |
 note | S | 0..* | Annotation | Additional information about the procedure |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | |
| Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
| Id | Grade | Path(s) | Details | Requirements |
| au-core-pro-04 | error | Procedure.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | AUBaseProcedure | A procedure in an Australian healthcare context | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 targetBodyStructure | 0..* | Reference(BodyStructure) | The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure | |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 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. |
 statusReason | SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| category | SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedure (extensible) |
| subject | SΣ | 1..1 | Reference(AU Core Patient) | Who the procedure was performed on |
| encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Encounter created as part of |
  performed[x] | SΣ | 1..1 | When the procedure was performed | |
 performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| performedString | string | |||
| performedAge | Age | |||
| performedRange | Range | |||
| recorder | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Who recorded the procedure |
| asserter | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Person who asserts this procedure |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | SΣ | 0..* | Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) | The justification that the procedure was performed |
| bodySite | SΣC | 0..* | CodeableConcept | Target body sites Binding: Body Site (extensible)au-core-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT |
| note | S | 0..* | Annotation | Additional information about the procedure |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| 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 | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | |
| Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | |
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | |
| Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
| Id | Grade | Path(s) | Details | Requirements |
| au-core-pro-04 | error | Procedure.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
| 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() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | AUBaseProcedure | A procedure in an Australian healthcare context | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| 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 | |||||
| targetBodyStructure | 0..* | Reference(BodyStructure) | The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure | |||||
| 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 | ?!SΣ | 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. | ||||
| statusReason | SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category | SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedure (extensible) | ||||
| subject | SΣ | 1..1 | Reference(AU Core Patient) | Who the procedure was performed on | ||||
| encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Encounter created as part of | ||||
| performed[x] | SΣ | 1..1 | When the procedure was performed | |||||
| performedDateTime | dateTime | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| recorder | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Who recorded the procedure | ||||
| asserter | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | 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 | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference | SΣ | 0..* | Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite | SΣC | 0..* | CodeableConcept | Target body sites Binding: Body Site (extensible)au-core-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | S | 0..* | Annotation | Additional information about the procedure | ||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| 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 | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | extensible | 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 |
| au-core-pro-04 | error | Procedure.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
| 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() |
This structure is derived from AUBaseProcedure
Summary
Mandatory: 2 elements
Must-Support: 13 elements
Structures
This structure refers to these other structures:
Maturity: 0
Differential View
This structure is derived from AUBaseProcedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | AUBaseProcedure | A procedure in an Australian healthcare context | |
| status | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
| statusReason | S | 0..1 | CodeableConcept | Reason for current status |
| category | S | 0..1 | CodeableConcept | Classification of the procedure |
| code | S | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedure (extensible) |
| subject | S | 1..1 | Reference(AU Core Patient) | Who the procedure was performed on |
| encounter | S | 0..1 | Reference(AU Core Encounter) | Encounter created as part of |
| performed[x] | S | 1..1 | dateTime, Period, string, Age, Range | When the procedure was performed |
| recorder | S | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Who recorded the procedure |
| asserter | S | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Person who asserts this procedure |
| reasonCode | S | 0..* | CodeableConcept | Coded reason procedure performed |
| reasonReference | S | 0..* | Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) | The justification that the procedure was performed |
| bodySite | SC | 0..* | CodeableConcept | Target body sites Binding: Body Site (extensible)au-core-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT |
| note | S | 0..* | Annotation | Additional information about the procedure |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | |
| Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
| Id | Grade | Path(s) | Details | Requirements |
| au-core-pro-04 | error | Procedure.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | AUBaseProcedure | A procedure in an Australian healthcare context | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| targetBodyStructure | 0..* | Reference(BodyStructure) | The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure | |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 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. |
| statusReason | SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| category | SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedure (extensible) |
| subject | SΣ | 1..1 | Reference(AU Core Patient) | Who the procedure was performed on |
| encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Encounter created as part of |
| performed[x] | SΣ | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| performedString | string | |||
| performedAge | Age | |||
| performedRange | Range | |||
| recorder | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Who recorded the procedure |
| asserter | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Person who asserts this procedure |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | SΣ | 0..* | Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) | The justification that the procedure was performed |
| bodySite | SΣC | 0..* | CodeableConcept | Target body sites Binding: Body Site (extensible)au-core-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT |
| note | S | 0..* | Annotation | Additional information about the procedure |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| 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 | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | |
| Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | |
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | |
| Procedure.bodySite | extensible | BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 |
| Id | Grade | Path(s) | Details | Requirements |
| au-core-pro-04 | error | Procedure.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
| 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() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | AUBaseProcedure | A procedure in an Australian healthcare context | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| 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 | |||||
| targetBodyStructure | 0..* | Reference(BodyStructure) | The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure | |||||
| 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 | ?!SΣ | 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. | ||||
| statusReason | SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category | SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Procedure (extensible) | ||||
| subject | SΣ | 1..1 | Reference(AU Core Patient) | Who the procedure was performed on | ||||
| encounter | SΣ | 0..1 | Reference(AU Core Encounter) | Encounter created as part of | ||||
| performed[x] | SΣ | 1..1 | When the procedure was performed | |||||
| performedDateTime | dateTime | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| recorder | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Who recorded the procedure | ||||
| asserter | SΣ | 0..1 | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | RelatedPerson) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | 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 | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference | SΣ | 0..* | Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite | SΣC | 0..* | CodeableConcept | Target body sites Binding: Body Site (extensible)au-core-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | S | 0..* | Annotation | Additional information about the procedure | ||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| 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 | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | extensible | 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 |
| au-core-pro-04 | error | Procedure.bodySite | If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists() | |
| 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() |
This structure is derived from AUBaseProcedure
Summary
Mandatory: 2 elements
Must-Support: 13 elements
Structures
This structure refers to these other structures:
Maturity: 0
Other representations of profile: CSV, Excel, Schematron
Below is an overview of the mandatory and optional search parameters and combined search parameters. FHIR search operations and the syntax used to describe the interactions is described here.
Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”. A few items are marked as MAY in this implementation guide to highlight their potential relevance.
| Parameter(s) | Conformance | Type(s) | Requirements (when used alone or in combination) |
|---|---|---|---|
| patient | SHALL | reference |
The client SHALL provide at least an id value and MAY provide both the Type and id values. The server SHALL support both. |
| patient+date | SHALL | reference+date |
|
| patient+code+date | SHOULD | reference+token+date |
|
| patient.identifier | SHOULD | reference.token |
The client SHALL provide both the system and code values. The server SHALL support both. The client SHOULD support search using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The server SHOULD support search using the using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. |
| patient+status | SHOULD | reference+token |
|
| code | MAY | token |
The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both. |
| date | MAY | date |
A client SHALL provide a value precise to the second + time offset. A server SHALL support a value precise to the second + time offset. |
| status | MAY | token |
The client SHALL provide at least a code value and MAY provide both the system and code values. The server SHALL support both. |
The following search parameters and search parameter combinations SHALL be supported:
patient search parameter:
_revinclude parameters: Provenance:targetpatient.identifier (e.g. patient.identifier=[system|][code])GET [base]/Procedure?patient={Type/}[id] or optionallyGET [base]/Procedure?patient.identifier=[system|][code]
Example:
Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient (how to search by reference and how to search by token)
patient and date search parameters:
patient.identifier (e.g. patient.identifier=[system|][code])date comparators: gt,lt,ge,ledate (e.g.date=[date]&date=[date]]&...)
GET [base]/Procedure?patient={Type/}[id]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}Example:
Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date (how to search by reference and how to search by date)
The following search parameters and search parameter combinations SHOULD be supported:
patient and code and date search parameters:
patient.identifier (e.g. patient.identifier=[system|][code])code (e.g.code={system|}[code],{system|}[code],...)date comparators: gt,lt,ge,ledate (e.g.date=[date]&date=[date]]&...)GET [base]/Procedure?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and date and procedure code(s). SHOULD support search by multiple codes. (how to search by reference and how to search by token and how to search by date)
patient and status search parameters:
patient.identifier (e.g. patient.identifier=[system|][code]status (e.g.status={system|}[code],{system|}[code],...)GET [base]/Procedure?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient and status (how to search by reference and how to search by token)
IG © 2022+ HL7 Australia. Package hl7.fhir.au.core#0.3.0-ballot based on FHIR 4.0.1. Generated 2024-03-10
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