Usage scenarios

The following are supported usage scenarios for this profile:

• Query for procedures performed on a patient
• Record or update a record of a procedure performed on a patient

Comparison with other national and international IGs

A resource conforming to this profile is conformant to:

• US Core Procedure
• and MAY be conformant to Procedure (IPS) if patient is supported as Procedure.subject.reference

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.

Profile specific implementation guidance

• 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.
• The use of coding can vary significantly across systems, requesters need to understand that they may encounter codes they do not recognise and be prepared to handle those resources appropriately. Responders SHOULD populate Procedure.code.text and/or Procedure.code.coding.display so that requesters can at least display the procedure even if the requester does not recognise the code supplied.
• Procedure.code contains the identification of the procedure which may include body site information. Where a system has information not supported by the coding in Procedure.code.coding (e.g. body site, laterality and other qualification of procedure coding terms) that information SHOULD be supplied in Procedure.code.text
• In an exchange with the My Health Record system Procedure.status is “completed”
• The Procedure resource can represent a reason as a code with Procedure.reasonCode, or a reference with Procedure.reasonReference to a Condition or other resource.
  • Although both are marked as Must Support, responders are not required to support both a code and a reference, but they SHALL support at least one of these elements
  • A requester SHALL support both elements
• A procedure including an implantable device should use Procedure.focalDevice with a reference to a Device resource

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from AUBaseProcedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	AUBaseProcedure	A procedure in an Australian healthcare context
status	SO	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
code	SO	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
subject	SO	1..1	Reference(AU Core Patient)	Who the procedure was performed on Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
encounter	SO	0..1	Reference(AU Core Encounter)	Encounter created as part of Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performed[x]	SO	0..1	dateTime, Period, string, Age, Range	When the procedure was performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonCode	SO	0..*	CodeableConcept	Coded reason procedure performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonReference	S	0..*	Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference)	The justification that the procedure was performed
bodySite	OC	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 Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

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
Slices for extension				Content/Rules for all slices
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	?!SOΣ	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. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
code	SOΣ	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
subject	SOΣ	1..1	Reference(AU Core Patient)	Who the procedure was performed on Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
encounter	SOΣ	0..1	Reference(AU Core Encounter)	Encounter created as part of Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performed[x]	SOΣ	0..1		When the procedure was performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
reasonCode	SOΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonReference	SΣ	0..*	Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference)	The justification that the procedure was performed
bodySite	OΣC	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 Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
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	?!SOΣ	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. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
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	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SOΣ	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
subject	SOΣ	1..1	Reference(AU Core Patient)	Who the procedure was performed on Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
encounter	SOΣ	0..1	Reference(AU Core Encounter)	Encounter created as part of Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performed[x]	SOΣ	0..1		When the procedure was performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	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	SOΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonReference	SΣ	0..*	Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference)	The justification that the procedure was performed
bodySite	OΣC	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 Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

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()

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	SO	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
code	SO	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
subject	SO	1..1	Reference(AU Core Patient)	Who the procedure was performed on Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
encounter	SO	0..1	Reference(AU Core Encounter)	Encounter created as part of Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performed[x]	SO	0..1	dateTime, Period, string, Age, Range	When the procedure was performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonCode	SO	0..*	CodeableConcept	Coded reason procedure performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonReference	S	0..*	Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference)	The justification that the procedure was performed
bodySite	OC	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 Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

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
Slices for extension				Content/Rules for all slices
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	?!SOΣ	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. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
code	SOΣ	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
subject	SOΣ	1..1	Reference(AU Core Patient)	Who the procedure was performed on Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
encounter	SOΣ	0..1	Reference(AU Core Encounter)	Encounter created as part of Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performed[x]	SOΣ	0..1		When the procedure was performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
reasonCode	SOΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonReference	SΣ	0..*	Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference)	The justification that the procedure was performed
bodySite	OΣC	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 Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir

Constraints

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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
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	?!SOΣ	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. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
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	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SOΣ	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible) Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
subject	SOΣ	1..1	Reference(AU Core Patient)	Who the procedure was performed on Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
encounter	SOΣ	0..1	Reference(AU Core Encounter)	Encounter created as part of Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performed[x]	SOΣ	0..1		When the procedure was performed Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	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	SOΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
reasonReference	SΣ	0..*	Reference(AU Core Condition | Observation | AU Core Procedure | DocumentReference)	The justification that the procedure was performed
bodySite	OΣC	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 Obligations Actor SHALL:populate-if-known AU Core Responder SHALL:no-error AU Core Requester
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	Procedure https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	BodySite https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 from https://tx.ontoserver.csiro.au/fhir
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

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: 1 element
Must-Support: 7 elements

Structures

This structure refers to these other structures:

• AU Core Patient (http://hl7.org.au/fhir/core/StructureDefinition/au-core-patient)
• AU Core Encounter (http://hl7.org.au/fhir/core/StructureDefinition/au-core-encounter)
• AU Core Condition (http://hl7.org.au/fhir/core/StructureDefinition/au-core-condition)
• AU Core Procedure (http://hl7.org.au/fhir/core/StructureDefinition/au-core-procedure)

Maturity: 1

Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU Core CapabilityStatements for a complete list of supported RESTful interactions for this IG.

FHIR search operations are described here and the syntax used to describe AU Core interactions is defined 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.

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

1. SHALL support searching using the patient search parameter:
   • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])

   GET [base]/Procedure?patient={Type/}[id] or optionallyGET [base]/Procedure?patient.identifier=[system|][code]

   Example:

   1. GET [base]/Procedure?patient=5678
   2. GET [base]/Procedure?patient.identifier=http://ns.electronichealth.net.au/id/medicare-number|32788511952
   3. GET [base]/Procedure?patient.identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608833357361

   Implementation Notes: Fetches a bundle of all Procedure resources for the specified patient (how to search by reference and how to search by token)

2. SHALL support searching using the combination of the patient and date search parameters:
   • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
   • SHALL support these date comparators: gt,lt,ge,le
   • SHOULD support multipleAnd search on date (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:

   1. GET [base]/Procedure?patient=5678&date=ge2020-01-01T00:00:00Z
   2. GET [base]/Procedure?patient.identifier=http://example.org/fhir/mrn|12345&date=ge2020-01-01T00:00:00Z

   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)

Optional Search Parameters

The following search parameters and search parameter combinations SHOULD be supported:

1. SHOULD support searching using the combination of the patient and code and date search parameters:
   • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code])
   • SHOULD support multipleOr search on code (e.g.code={system|}[code],{system|}[code],...)
   • SHALL support these date comparators: gt,lt,ge,le
   • SHOULD support multipleAnd search on date (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:

   1. GET [base]/Procedure?patient=5678&code=http://snomed.info/sct|26782000,http://snomed.info/sct|36969009&date=ge2020-01-01T00:00:00Z
   2. GET [base]/Procedure?patient.identifier=http://example.org/fhir/mrn|12345&code=http://snomed.info/sct|26782000,http://snomed.info/sct|36969009&date=ge2020-01-01T00:00:00Z

   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)

2. SHOULD support searching using the combination of the patient and status search parameters:
   • SHOULD support chained searching of patient canonical identifier patient.identifier (e.g. patient.identifier=[system|][code]
   • SHALL support multipleOr search on status (e.g.status={system|}[code],{system|}[code],...)

   GET [base]/Procedure?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

   Example:

   1. GET [base]/Procedure?patient=5678&status=completed

   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)