HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.1.0 - STU1 Release 1.1 - Standard for Trial-Use International flag

This page is part of the HRSA Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+ or uds-plus) FHIR IG (v1.1.0: STU1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: De-Identified UDS Plus Procedure

Official URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-procedure Version: 1.1.0
Standards status: Trial-use Maturity Level: 2 Computable Name: UDSPlusProcedure

The UDS+ profile is based on the Procedure resource and establishes the core elements, extensions, vocabularies and value sets for representing procedures for UDS+ program.

Introduction

This profile is used to represent de-identified Procedure information. The de-identification process has to remove all data elements not explicitly identified as "SUPPORTED" in the profile.

The HHS De-identification Guidance is to be followed to ensure appropriate level of de-identification is performed.

According to the HHS guidance, dates should not have a precision of more than the year. This means month and day cannot be included. This includes Procedure.occurenceDateTime.

In FHIR Resources, text elements and reference.display elements which provide human readable information to the providers may be generated using programs and tools from the data present within the resource. For e.g a Procedure resource text element may contain information such as the Procedure date, patient information. This type of information will enable identification of the individuals. In order to avoid inadvertent revealing of PII/PHI, text elements cannot be included in the De-identified FHIR resource and the submission will be rejected when text elements are present by the validation process.

Ids and References

The original Procedure resource id should not be included in the De-identified Procedure instance. Instead a new id should be created and provided as part of the FHIR resource. The Data Submitter should be capable of using the generated id to relink the data to the original Procedure. All resource references to the Procedure submitted as part of the UDS+ report should refer to newly generated id.

Resource references cannot contain text element as it may contain PHI/PII. The text element for following references are not allowed

  • subject
  • encounter

Date Truncation

The Data Submitter has to truncate the following dates to only have a precision of year

  • performedDateTime
  • extension.recordedDate

Usage:

Formal Views of Profile Content

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

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id S 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... text 0..0
... contained 0..0
.... recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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
... code S 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures

... subject S 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
.... display 0..0
... encounter S 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... display 0..0
... performed[x] SC 0..1 When the procedure was performed
uds-plus-proc-1: All dateTime data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-2: All Period.start data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-3: All Period.emd data elements should be truncated to a year only for de-identified resources.
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedAge Age
.... performedString string
.... performedRange Range
... recorder
.... display 0..0
... asserter
.... display 0..0
... performer S 0..* BackboneElement The people who performed the procedure
.... actor
..... display 0..0
... bodySite S 0..* CodeableConcept Target body sites
... note 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code

Constraints

IdGradePath(s)DetailsRequirements
uds-plus-proc-1errorProcedure.performed[x]All dateTime data elements should be truncated to a year only for de-identified resources.
: $this is DateTime implies $this.toString().length() = 4
uds-plus-proc-2errorProcedure.performed[x]All Period.start data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.start.exists() implies $this.start.toString().length() = 4
uds-plus-proc-3errorProcedure.performed[x]All Period.emd data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.end.exists() implies $this.end.toString().length() = 4
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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.

... code SΣ 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures

... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] SΣC 0..1 When the procedure was performed
uds-plus-proc-1: All dateTime data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-2: All Period.start data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-3: All Period.emd data elements should be truncated to a year only for de-identified resources.
.... performedDateTime dateTime
... performer SΣ 0..* BackboneElement The people who performed the procedure
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
uds-plus-proc-1errorProcedure.performed[x]All dateTime data elements should be truncated to a year only for de-identified resources.
: $this is DateTime implies $this.toString().length() = 4
uds-plus-proc-2errorProcedure.performed[x]All Period.start data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.start.exists() implies $this.start.toString().length() = 4
uds-plus-proc-3errorProcedure.performed[x]All Period.emd data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.end.exists() implies $this.end.toString().length() = 4
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... 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 BindingsPurpose
AllLanguages Max Binding
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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 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 SΣ 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures

... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... performed[x] SΣC 0..1 When the procedure was performed
uds-plus-proc-1: All dateTime data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-2: All Period.start data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-3: All Period.emd data elements should be truncated to a year only for de-identified resources.
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedAge Age
.... performedString string
.... performedRange Range
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... performer SΣ 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location Σ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... 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.


... 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.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.encounter.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.recorder.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.asserter.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.performer.actor.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
uds-plus-proc-1errorProcedure.performed[x]All dateTime data elements should be truncated to a year only for de-identified resources.
: $this is DateTime implies $this.toString().length() = 4
uds-plus-proc-2errorProcedure.performed[x]All Period.start data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.start.exists() implies $this.start.toString().length() = 4
uds-plus-proc-3errorProcedure.performed[x]All Period.emd data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.end.exists() implies $this.end.toString().length() = 4

This structure is derived from Procedure

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id S 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... text 0..0
... contained 0..0
.... recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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
... code S 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures

... subject S 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
.... display 0..0
... encounter S 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... display 0..0
... performed[x] SC 0..1 When the procedure was performed
uds-plus-proc-1: All dateTime data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-2: All Period.start data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-3: All Period.emd data elements should be truncated to a year only for de-identified resources.
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedAge Age
.... performedString string
.... performedRange Range
... recorder
.... display 0..0
... asserter
.... display 0..0
... performer S 0..* BackboneElement The people who performed the procedure
.... actor
..... display 0..0
... bodySite S 0..* CodeableConcept Target body sites
... note 0..0

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code

Constraints

IdGradePath(s)DetailsRequirements
uds-plus-proc-1errorProcedure.performed[x]All dateTime data elements should be truncated to a year only for de-identified resources.
: $this is DateTime implies $this.toString().length() = 4
uds-plus-proc-2errorProcedure.performed[x]All Period.start data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.start.exists() implies $this.start.toString().length() = 4
uds-plus-proc-3errorProcedure.performed[x]All Period.emd data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.end.exists() implies $this.end.toString().length() = 4

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension Content/Rules for all slices
.... recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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.

... code SΣ 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures

... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
... performed[x] SΣC 0..1 When the procedure was performed
uds-plus-proc-1: All dateTime data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-2: All Period.start data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-3: All Period.emd data elements should be truncated to a year only for de-identified resources.
.... performedDateTime dateTime
... performer SΣ 0..* BackboneElement The people who performed the procedure
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
uds-plus-proc-1errorProcedure.performed[x]All dateTime data elements should be truncated to a year only for de-identified resources.
: $this is DateTime implies $this.toString().length() = 4
uds-plus-proc-2errorProcedure.performed[x]All Period.start data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.start.exists() implies $this.start.toString().length() = 4
uds-plus-proc-3errorProcedure.performed[x]All Period.emd data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.end.exists() implies $this.end.toString().length() = 4

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..* Procedure De-Identified UDS Plus Procedure
... id SΣ 0..1 id The de-identified Procedure identifier created by the health center to send data to UDS+ Data Receiver
... 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 BindingsPurpose
AllLanguages Max Binding
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... recordedDate S 0..1 dateTime Indicates the recorded date of a clinical event
URL: http://fhir.org/guides/hrsa/uds-plus/StructureDefinition/uds-plus-recordedDate-extension
... 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 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 SΣ 1..1 CodeableConcept Identification of the procedure
Binding: US Core Procedure Codes (extensible): The set of codes indicating the procedures

... subject SΣ 1..1 Reference(De-Identified UDS Plus Patient) Who the procedure was performed on
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... encounter SΣ 0..1 Reference(De-Identified UDS Plus Encounter) Encounter created as part of
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... performed[x] SΣC 0..1 When the procedure was performed
uds-plus-proc-1: All dateTime data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-2: All Period.start data elements should be truncated to a year only for de-identified resources.
uds-plus-proc-3: All Period.emd data elements should be truncated to a year only for de-identified resources.
.... performedDateTime dateTime S
.... performedPeriod Period
.... performedAge Age
.... performedString string
.... performedRange Range
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
... performer SΣ 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location Σ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite SΣ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... 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.


... 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.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Procedure.statusrequiredEventStatus
http://hl7.org/fhir/ValueSet/event-status|4.0.1
from the FHIR Standard
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
from the FHIR Standard
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-category
from the FHIR Standard
Procedure.codeextensibleUSCoreProcedureCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
Procedure.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.encounter.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.recorder.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.asserter.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.performer.functionexampleProcedurePerformerRoleCodes
http://hl7.org/fhir/ValueSet/performer-role
from the FHIR Standard
Procedure.performer.actor.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
Procedure.reasonCodeexampleProcedureReasonCodes
http://hl7.org/fhir/ValueSet/procedure-reason
from the FHIR Standard
Procedure.bodySiteexampleSNOMEDCTBodyStructures
http://hl7.org/fhir/ValueSet/body-site
from the FHIR Standard
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-outcome
from the FHIR Standard
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
http://hl7.org/fhir/ValueSet/condition-code
from the FHIR Standard
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
http://hl7.org/fhir/ValueSet/procedure-followup
from the FHIR Standard
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
http://hl7.org/fhir/ValueSet/device-action
from the FHIR Standard
Procedure.usedCodeexampleFHIRDeviceTypes
http://hl7.org/fhir/ValueSet/device-kind
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
uds-plus-proc-1errorProcedure.performed[x]All dateTime data elements should be truncated to a year only for de-identified resources.
: $this is DateTime implies $this.toString().length() = 4
uds-plus-proc-2errorProcedure.performed[x]All Period.start data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.start.exists() implies $this.start.toString().length() = 4
uds-plus-proc-3errorProcedure.performed[x]All Period.emd data elements should be truncated to a year only for de-identified resources.
: $this is Period and Period.end.exists() implies $this.end.toString().length() = 4

This structure is derived from Procedure

 

Other representations of profile: CSV, Excel, Schematron