HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.1.0 - STU1 Release 1.1 - Standard for Trial-Use
HRSA 2023 Uniform Data System (UDS) Patient Level Submission (PLS) (UDS+) FHIR IG
1.1.0 - STU1 Release 1.1 - Standard for Trial-Use
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. For a full list of available versions, see the Directory of published versions
| 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.
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
Date Truncation
The Data Submitter has to truncate the following dates to only have a precision of year
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  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 | |||
  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 |
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 | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code |
| Id | Grade | Path(s) | Details | Requirements |
| uds-plus-proc-1 | error | Procedure.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-2 | error | Procedure.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-3 | error | Procedure.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 |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
| statusReason |
SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| 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. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| uds-plus-proc-1 | error | Procedure.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-2 | error | Procedure.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-3 | error | Procedure.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 |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
 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. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
| Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.recorder.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.asserter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.performer.actor.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| uds-plus-proc-1 | error | Procedure.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-2 | error | Procedure.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-3 | error | Procedure.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
Summary
Mandatory: 3 elements
Must-Support: 10 elements
Prohibited: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 | |||
| 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 |
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 | |||
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code |
| Id | Grade | Path(s) | Details | Requirements |
| uds-plus-proc-1 | error | Procedure.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-2 | error | Procedure.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-3 | error | Procedure.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
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. |
| statusReason |
SΣ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. |
| 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. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | |
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| uds-plus-proc-1 | error | Procedure.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-2 | error | Procedure.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-3 | error | Procedure.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
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| 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. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code | ||||
| Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.recorder.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.asserter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.performer.actor.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| 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() | |
| uds-plus-proc-1 | error | Procedure.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-2 | error | Procedure.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-3 | error | Procedure.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
Summary
Mandatory: 3 elements
Must-Support: 10 elements
Prohibited: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron