Argonaut Data Query Implementation Guide Version 1.0.0

This page is part of the Argonaut Data Query Implementation Guide (v1.0.0: Release) based on FHIR R2. This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

D.4.1.4 StructureDefinition:Argonaut Procedure Profile - Detailed Descriptions

Definitions for the StructureDefinition-argo-procedure Profile.

Procedure(argoprofile)
Definition

An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.

Control0..*
InvariantsDefined on this element
pro-1: Reason not performed is only permitted if notPerformed indicator is true (: )
Procedure.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

Procedure.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Procedure.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

Procedure.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Procedure.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Procedure.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Procedure.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.identifier
Definition

This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Procedure.subject
Definition

The person, animal or group on which the procedure was performed.

Control1..1
TypeReference(Argonaut Patient Profile)
Must Supporttrue
Procedure.status
Definition

A code specifying the state of the procedure. Generally this will be in-progress or completed state.

Control1..1
Bindingnull
The codes SHALL be taken from ProcedureStatus
Typecode
Is Modifiertrue
Must Supporttrue
Procedure.category
Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Control0..1
BindingA code that classifies a procedure for searching, sorting and display purposes.
For example codes, see Procedure Category Codes (SNOMED CT)
TypeCodeableConcept
Procedure.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Control1..1
BindingCodes describing the Procedure Type
The codes SHALL be taken from Argonaut ProcedureType; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Procedure.notPerformed
Definition

Set this to true if the record is saying that the procedure was NOT performed.

Control0..1
Typeboolean
Is Modifiertrue
Default Valuefalse
Procedure.reasonNotPerformed
Definition

A code indicating why the procedure was not performed.

Control0..* This element is affected by the following invariants: pro-1
BindingA code that identifies the reason a procedure was not performed.
For example codes, see Procedure Not Performed Reason (SNOMED-CT)
TypeCodeableConcept
Procedure.bodySite
Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Control0..*
BindingCodes describing anatomical locations. May include laterality.
For example codes, see SNOMED CT Body Structures
TypeCodeableConcept
Procedure.reason[x]
Definition

The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.

Control0..1
BindingA code that identifies the reason a procedure is required.
For example codes, see Procedure Reason Codes
TypeChoice of: CodeableConcept, Reference(Condition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.

Procedure.performer
Definition

Limited to 'real' people rather than equipment.

Control0..*
TypeBackboneElement
Procedure.performer.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Procedure.performer.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.performer.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.performer.actor
Definition

The practitioner who was involved in the procedure.

Control0..1
TypeChoice of: Reference(Practitioner), Reference(Organization), Reference(Patient), Reference(RelatedPerson)
Procedure.performer.role
Definition

For example: surgeon, anaethetist, endoscopist.

Control0..1
BindingA code that identifies the role of a performer of the procedure.
For example codes, see Procedure Performer Role Codes
TypeCodeableConcept
Procedure.performed[x]
Definition

The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Control1..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Procedure.encounter
Definition

The encounter during which the procedure was performed.

Control0..1
TypeReference(Encounter)
Procedure.location
Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Control0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Procedure.outcome
Definition

The outcome of the procedure - did it resolve reasons for the procedure being performed?

Control0..1
BindingAn outcome of a procedure - whether it was resolved or otherwise.
For example codes, see Procedure Outcome Codes (SNOMED CT)
TypeCodeableConcept
Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Procedure.report
Definition

This could be a histology result, pathology report, surgical report, etc..

Control0..*
TypeReference(DiagnosticReport)
Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Procedure.complication
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Control0..*
BindingCodes describing complications that resulted from a procedure.
For example codes, see Condition/Problem/Diagnosis Codes
TypeCodeableConcept
Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Procedure.followUp
Definition

If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.

Control0..*
BindingSpecific follow up required for a procedure e.g. removal of sutures.
For example codes, see Procedure Follow up Codes (SNOMED CT)
TypeCodeableConcept
Procedure.request
Definition

A reference to a resource that contains details of the request for this procedure.

Control0..1
TypeChoice of: Reference(CarePlan), Reference(DiagnosticOrder), Reference(ProcedureRequest), Reference(ReferralRequest)
Procedure.notes
Definition

Any other notes about the procedure. E.g. the operative notes.

Control0..*
TypeAnnotation
Procedure.focalDevice
Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Control0..*
TypeBackboneElement
Procedure.focalDevice.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Procedure.focalDevice.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.focalDevice.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Procedure.focalDevice.action
Definition

The kind of change that happened to the device during the procedure.

Control0..1
BindingA kind of change that happened to the device during the procedure.
The codes SHALL be taken from Procedure Device Action Codes
TypeCodeableConcept
Procedure.focalDevice.manipulated
Definition

The device that was manipulated (changed) during the procedure.

Control1..1
TypeReference(Device)
Procedure.used
Definition

Identifies medications, devices and any other substance used as part of the procedure.

Control0..*
TypeChoice of: Reference(Device), Reference(Medication), Reference(Substance)
Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.