Implementierungsleitfaden IsiK-Basismodul 1.0.0 CC

Prozedur (Procedure)

Motivation

Die Möglichkeit, auf eine Übersicht der Prozeduren eines Patienten zuzugreifen, Patienten anhand durchgeführter oder geplanter Prozeduren zu suchen, oder zu prüfen, ob eine konkrete Prozedur bei einem Patienten durchgeführt wurde, sind wichtige Funktionen im klinischen Behandlungsablauf.

In FHIR werden Prozeduren mit der Procedure-Ressource repräsentiert.

Da die Prozeduren in klinischen Primärsystemen in der Regel in OPS-codierter Form vorliegen, fordert ISiK in erster Linie diese Form des Austausches. Falls eine Prozedur zwar dokumentiert aber noch nicht codiert wurde (z.B. wenn die Kodierung erst nach der Entlassung erfolgt), ist alternativ eine Repräsentation als Freitext-Prozedur möglich.

Kompatibilität

Dieses Profil basiert auf dem Profil "Prozedur" der Medizininformatik-Initative.

Instanzen, die gegen ISiKProzedur valide sind, sind auch valide gegen

Profil "Prozedur" der Medizininformatik-Initative
- wenn unter Procedure.code.coding mindestens eine codierte Darstellung der Prozedur angegeben wurde

Profil

Canonical URL: https://gematik.de/fhir/ISiK/StructureDefinition/ISiKProzedur

Procedure			Procedure	Element Id Procedure Short description An action that is being or was performed on a patient Definition An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. Data Type Procedure Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: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-3: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-6:A resource should have narrative for robust management text.`div`.exists() dom-5:If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` proc-ISiK-1:Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden `code.coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()` proc-ISiK-2:Falls eine codierte Prozedur vorliegt MUSS eine kodierte Category abgebildet werden `code.coding.exists() implies category.coding.exists()` Mappings rim:Entity. Role, or Act workflow:Event rim:Procedure[moodCode=EVN]
id	S Σ	1..1	System.String	There are no (further) constraints on this element Element Id Procedure.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. 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. Data Type System.String
extension		0..*	Extension	Element Id Procedure.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data Type Extension Sliced: Unordered, Open, by url(Value) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
Dokumentationsdatum	S	0..1	Extension(dateTime)	Element Id Procedure.extension:Dokumentationsdatum Short description Dokumentationsdatum der Prozedur Alternate names extensions, user content Definition Dokumentationsdatum der Prozedur, falls abweichend vom Durchführungsdatum 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. Data Type Extension(dateTime) Extension URL https://gematik.de/fhir/ISiK/StructureDefinition/Prozedur_Dokumentationsdatum Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element Id Procedure.identifier Short description External Identifiers for this procedure Definition Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. Requirements Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. Comments This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier workflow:Event.identifier w5:FiveWs.identifier v2:Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4 rim:.id
instantiatesCanonical	Σ	0..*	canonical	There are no (further) constraints on this element Element Id Procedure.instantiatesCanonical Short description Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. Comments see Canonical References Data Type canonical Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Event.instantiatesCanonical rim:.outboundRelationship[typeCode=DEFN].target
instantiatesUri	Σ	0..*	uri	There are no (further) constraints on this element Element Id Procedure.instantiatesUri Short description Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. Comments This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Event.instantiatesUri rim:.outboundRelationship[typeCode=DEFN].target
basedOn	Σ	0..*	Reference(CarePlan\| ServiceRequest)	There are no (further) constraints on this element Element Id Procedure.basedOn Short description A request for this procedure Alternate names fulfills Definition A reference to a resource that contains details of the request for this procedure. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(CarePlan\| ServiceRequest) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.basedOn rim:.outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
partOf	Σ	0..*	Reference(Procedure\| Observation\| MedicationAdministration)	There are no (further) constraints on this element Element Id Procedure.partOf Short description Part of referenced event Alternate names container Definition A larger event of which this particular procedure is a component or step. Comments The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). Data Type Reference(Procedure\| Observation\| MedicationAdministration) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.partOf rim:.inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
status	S Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id Procedure.status Short description preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Definition A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. Comments The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data Type code Binding EventStatus (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Event.status w5:FiveWs.status rim:statusCode
statusReason	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.statusReason Short description Reason for current status Alternate names Suspended Reason, Cancelled Reason Definition Captures the reason for the current state of the procedure. Comments This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. Data Type CodeableConcept Binding ProcedureNotPerformedReason(SNOMED-CT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.statusReason rim:.reason.Observation.value
category	S Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.category Short description Classification of the procedure Definition A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure"). Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data Type CodeableConcept Binding ProcedureCategoryCodes(SNOMEDCT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.class rim:.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
coding	Σ	0..*	Coding	Element Id Procedure.category.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Sliced: Unordered, Open, by system(Pattern) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
SNOMED-CT	S Σ	0..1	CodingBinding	Element Id Procedure.category.coding:SNOMED-CT Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Binding ProzedurenKategorie-SCT (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	S Σ	1..1	uri	Element Id Procedure.category.coding:SNOMED-CT.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://snomed.info/sct Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.category.coding:SNOMED-CT.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	There are no (further) constraints on this element Element Id Procedure.category.coding:SNOMED-CT.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.category.coding:SNOMED-CT.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element Id Procedure.category.coding:SNOMED-CT.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.category.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
code	S Σ	0..1	CodeableConcept	Element Id Procedure.code Short description Identification of the procedure Alternate names type Definition The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy"). Requirements 0..1 to account for primarily narrative only resources. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data Type CodeableConcept Binding ProcedureCodes(SNOMEDCT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` sct-ops-1:Falls die Prozedur kodiert vorliegt, SOLL mindestens ein OPS oder SNOMED-CT Code angegeben werden. Ansonsten Freitext. `coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists() or text.exists()` proc-ISiK-3:Entweder MUSS eine kodierte Prozedur vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. `coding.exists().not() implies text.exists()` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.code w5:FiveWs.what[x] v2:OBR-44/OBR-45 rim:.code
coding	S Σ	0..*	Coding	Element Id Procedure.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Sliced: Unordered, Open, by system(Pattern) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
OPS	S Σ	0..1	CodingBinding	Element Id Procedure.code.coding:OPS Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Binding http://fhir.de/ValueSet/dimdi/ops (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
extension		0..*	Extension	Element Id Procedure.code.coding:OPS.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data Type Extension Sliced: Unordered, Open, by url(Value) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
Seitenlokalisation	S	0..1	Extension(Coding)	Element Id Procedure.code.coding:OPS.extension:Seitenlokalisation Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. 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. Data Type Extension(Coding) Extension URL http://fhir.de/StructureDefinition/seitenlokalisation Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
system	S Σ	1..1	uri	Element Id Procedure.code.coding:OPS.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://fhir.de/CodeSystem/dimdi/ops Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	S Σ	1..1	string	There are no (further) constraints on this element Element Id Procedure.code.coding:OPS.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	There are no (further) constraints on this element Element Id Procedure.code.coding:OPS.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.code.coding:OPS.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element Id Procedure.code.coding:OPS.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
SNOMED-CT	Σ	0..1	CodingBinding	Element Id Procedure.code.coding:SNOMED-CT Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data Type Coding Binding ProzedurenCodes-SCT (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	S Σ	1..1	uri	Element Id Procedure.code.coding:SNOMED-CT.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://snomed.info/sct Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.code.coding:SNOMED-CT.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	There are no (further) constraints on this element Element Id Procedure.code.coding:SNOMED-CT.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.code.coding:SNOMED-CT.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element Id Procedure.code.coding:SNOMED-CT.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	S Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.code.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
subject	S Σ	1..1	Reference(Patient\| Group)	There are no (further) constraints on this element Element Id Procedure.subject Short description Who the procedure was performed on Alternate names patient Definition The person, animal or group on which the procedure was performed. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Patient\| Group) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.subject w5:FiveWs.subject[x] v2:PID-3 rim:.participation[typeCode=SBJ].role w5:FiveWs.subject
reference	S Σ	1..1	string	There are no (further) constraints on this element Element Id Procedure.subject.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:N/A
type	Σ	0..1	uriBinding	There are no (further) constraints on this element Element Id Procedure.subject.type Short description Type the reference refers to (e.g. "Patient") Definition The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). Comments This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Data Type uri Binding ResourceType (extensible) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element Id Procedure.subject.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation\|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier rim:.identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Procedure.subject.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:N/A
encounter	S Σ	0..1	Reference(Encounter)	There are no (further) constraints on this element Element Id Procedure.encounter Short description Encounter created as part of Definition The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. Comments This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. Data Type Reference(Encounter) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.context w5:FiveWs.context v2:PV1-19 rim:.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
performed[x]	S Σ	1..1		There are no (further) constraints on this element Element Id Procedure.performed[x] Short description When the procedure was performed Definition Estimated or actual date, date-time, period, or age when 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. Comments Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Event.occurrence[x] w5:FiveWs.done[x] v2:OBR-7 rim:.effectiveTime
performedDateTime			dateTime	Data Type dateTime
performedPeriod			Period	Data Type Period
recorder	Σ	0..1	Reference(Patient\| RelatedPerson\| Practitioner\| PractitionerRole)	There are no (further) constraints on this element Element Id Procedure.recorder Short description Who recorded the procedure Definition Individual who recorded the record and takes responsibility for its content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Patient\| RelatedPerson\| Practitioner\| PractitionerRole) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.author rim:.participation[typeCode=AUT].role
asserter	Σ	0..1	Reference(Patient\| RelatedPerson\| Practitioner\| PractitionerRole)	There are no (further) constraints on this element Element Id Procedure.asserter Short description Person who asserts this procedure Definition Individual who is making the procedure statement. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Patient\| RelatedPerson\| Practitioner\| PractitionerRole) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.source rim:.participation[typeCode=INF].role
performer	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element Id Procedure.performer Short description The people who performed the procedure Definition Limited to "real" people rather than equipment. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Event.performer rim:.participation[typeCode=PRF]
function	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.performer.function Short description Type of performance Definition Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Requirements Allows disambiguation of the types of involvement of different performers. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data Type CodeableConcept Binding ProcedurePerformerRoleCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.performer.function v2:Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25 rim:.functionCode
actor	Σ	1..1	Reference(Practitioner\| PractitionerRole\| Organization\| Patient\| RelatedPerson\| Device)	There are no (further) constraints on this element Element Id Procedure.performer.actor Short description The reference to the practitioner Definition The practitioner who was involved in the procedure. Requirements A reference to Device supports use cases, such as pacemakers. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Practitioner\| PractitionerRole\| Organization\| Patient\| RelatedPerson\| Device) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.performer.actor w5:FiveWs.actor v2:ORC-19/PRT-5 rim:.role
onBehalfOf		0..1	Reference(Organization)	There are no (further) constraints on this element Element Id Procedure.performer.onBehalfOf Short description Organization the device or practitioner was acting for Definition The organization the device or practitioner was acting on behalf of. Requirements Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Organization) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.scoper
location	Σ	0..1	Reference(Location)	There are no (further) constraints on this element Element Id Procedure.location Short description Where the procedure happened Definition The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Requirements Ties a procedure to where the records are likely kept. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Location) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.where[x] rim:.participation[typeCode=LOC].role[classCode=SDLOC]
reasonCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.reasonCode Short description Coded reason procedure performed Definition The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. Comments Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Data Type CodeableConcept Binding ProcedureReasonCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.reasonCode w5:FiveWs.why[x] rim:.reasonCode
reasonReference	Σ	0..*	Reference(Condition\| Observation\| Procedure\| DiagnosticReport\| DocumentReference)	There are no (further) constraints on this element Element Id Procedure.reasonReference Short description The justification that the procedure was performed Definition The justification of why the procedure was performed. Comments It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Data Type Reference(Condition\| Observation\| Procedure\| DiagnosticReport\| DocumentReference) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.reasonReference w5:FiveWs.why[x] rim:.reasonCode
bodySite	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.bodySite Short description Target body sites Definition Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. Comments If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure. Data Type CodeableConcept Binding SNOMEDCTBodyStructures (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:OBX-20 rim:.targetSiteCode
outcome	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.outcome Short description The result of procedure Definition The outcome of the procedure - did it resolve the reasons for the procedure being performed? Comments If outcome contains narrative text only, it can be captured using the CodeableConcept.text. Data Type CodeableConcept Binding ProcedureOutcomeCodes(SNOMEDCT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode=OUT].target.text
report		0..*	Reference(DiagnosticReport\| DocumentReference\| Composition)	There are no (further) constraints on this element Element Id Procedure.report Short description Any report resulting from the procedure Definition This could be a histology result, pathology report, surgical report, etc. 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. Data Type Reference(DiagnosticReport\| DocumentReference\| Composition) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
complication		0..*	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.complication Short description Complication following the procedure 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. Comments If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Data Type CodeableConcept Binding Condition/Problem/DiagnosisCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
complicationDetail		0..*	Reference(Condition)	There are no (further) constraints on this element Element Id Procedure.complicationDetail Short description A condition that is a result of the procedure Definition Any complications that occurred during the procedure, or in the immediate post-performance period. Requirements This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Condition) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
followUp		0..*	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.followUp Short description Instructions for follow up Definition If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data Type CodeableConcept Binding ProcedureFollowUpCodes(SNOMEDCT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
note	S	0..*	Annotation	There are no (further) constraints on this element Element Id Procedure.note Short description Additional information about the procedure Definition Any other notes and comments about the procedure. Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). Data Type Annotation Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:N/A rim:Act workflow:Event.note v2:NTE rim:.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
focalDevice		0..*	BackboneElement	There are no (further) constraints on this element Element Id Procedure.focalDevice Short description Manipulated, implanted, or removed device 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. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:.participation[typeCode=DEV].role[classCode=MANU]
action		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element Id Procedure.focalDevice.action Short description Kind of change to device Definition The kind of change that happened to the device during the procedure. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data Type CodeableConcept Binding ProcedureDeviceActionCodes (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
manipulated		1..1	Reference(Device)	There are no (further) constraints on this element Element Id Procedure.focalDevice.manipulated Short description Device that was changed Definition The device that was manipulated (changed) during the procedure. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type Reference(Device) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode=DEV].role[classCode=SDLOC]
usedReference		0..*	Reference(Device\| Medication\| Substance)	There are no (further) constraints on this element Element Id Procedure.usedReference Short description Items used during procedure Definition Identifies medications, devices and any other substance used as part of the procedure. Requirements Used for tracking contamination, etc. Comments For devices actually implanted or removed, use Procedure.device. Data Type Reference(Device\| Medication\| Substance) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.participation[typeCode=DEV].role[classCode=MANU] or .participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)
usedCode		0..*	CodeableConcept	There are no (further) constraints on this element Element Id Procedure.usedCode Short description Coded items used during the procedure Definition Identifies coded items that were used as part of the procedure. Comments For devices actually implanted or removed, use Procedure.device. Data Type CodeableConcept Binding FHIRDeviceTypes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:participation[typeCode=Dev].role[classCode=MANU]

Link Simplifier Profil Übersicht

Folgende FHIRPath-Constraints sind im Profil zu beachten:

proc-ISiK-1	error	Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden	code.coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
proc-ISiK-2	error	Falls eine codierte Prozedur vorliegt MUSS eine kodierte Category abgebildet werden	code.coding.exists() implies category.coding.exists()
sct-ops-1	error	Falls die Prozedur kodiert vorliegt, SOLL mindestens ein OPS oder SNOMED-CT Code angegeben werden. Ansonsten Freitext.	coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists() or text.exists()
proc-ISiK-3	error	Entweder MUSS eine kodierte Prozedur vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt.	coding.exists().not() implies text.exists()

Anmerkungen zu den Must-Support Feldern

`Procedure.extension:recordedDate`

Bedeutung: Das Dokumentationsdatum der Prozedur MUSS zu Qualitätssicherungszwecken angegeben werden. Dies ist das fachliche Dokumentationsdatum, nicht zu verwechseln mit der technischen Anlage des Datensatzes im Primärsystem. Diese beiden Daten können jedoch identisch sein.

`Procedure.status`

Bedeutung: Kodierter klinischer Status der Prozedur. MUSS angegeben werden, da die Interpretation der Prozedur davon abhängt ob diese 'completed' ist oder einen anderen Status aufweist.

`Procedure.category`

Bedeutung: Zur groben Kategorisierung MUSS eine Kodierung auf Basis der OPS-Klassencodes erfolgen. Eine ConceptMap für das Mapping von OPS-Kodes -> Kategorie findet sich in den Deutschen Basisprofilen - Implementierungsleitfaden Abschnitt Terminologien. Die Angabe der Kategeorie MUSS nur für OPS-kodierte Prozeduren erfolgen.

`Procedure.code.coding`

Bedeutung: Codierte Prozedur. Entweder kodiert per OPS oder SNOMED CT. Bei der Kodierung per SNOMED CT ist das ValueSet ProzedurenCodes-SCT zu beachten.

`Procedure.code.text`

Bedeutung: Freitext-Beschreibung der Prozedur

`Procedure.performed`

Bedeutung: Zur zeitlichen Einordnung der Prozedur KANN das Durchführungsdatum der Prozedur dokumentiert werden. Mindestens MUSS der Beginn der Prozedur dokumentiert werden, das Ende KANN implementiert werden.

`Procedure.subject`

Bedeutung: Ein Patientenbezug der Prozedur MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.

`Procedure.note`

Bedeutung: Weitere optionale Freitext-Notizen bezogen auf die durchgeführte Prozedur.

Interaktionen

Für die Ressource Procedure MUSS die REST-Interaktion "READ" implementiert werden.

Folgende Suchparameter sind für das Bestätigungsverfahren relevant, auch in Kombination:

Der Suchparameter "_id" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?_id=test

Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "status" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?status=http://hl7.org/fhir/event-status|entered-in-error

Anwendungshinweise: Weitere Informationen zur Suche nach "Procedure.status" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".
Der Suchparameter "category" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?category=http://snomed.info/sct|387713003

Anwendungshinweise: Weitere Informationen zur Suche nach "Procedure.category" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".
Der Suchparameter "code" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?code=http://fhir.de/CodeSystem/dimdi/ops|5-470

Anwendungshinweise: Weitere Informationen zur Suche nach "Procedure.code" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".
Der Suchparameter "subject" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?subject=Patient/123

Anwendungshinweise: Weitere Informationen zur Suche nach "Procedure.subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Der Suchparameter "patient" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?patient=Patient/123

Anwendungshinweise: Weitere Informationen zur Suche nach "patient" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".

Dieser Suchparameter ist für die Umsetzung des IHE QEDm Profils verpflichend.
Der Suchparameter "encounter" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?encounter=Encounter/123

Anwendungshinweise: Weitere Informationen zur Suche nach "encounter" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Der Suchparameter "date" MUSS unterstützt werden:

Beispiele:

GET [base]/Procedure?date=lt2020-26-10

Anwendungshinweise: Weitere Informationen zur Suche nach "date" finden sich in der FHIR-Basisspezifikation - Abschnitt "Date Search".

Dieser Suchparameter ist für die Umsetzung des IHE QEDm Profils verpflichend.
Der Suchparameter für "_profile" KANN unterstützt werden:

Beispiele:

GET [base]/Procedure?_profile=https://gematik.de/fhir/ISiK/StructureDefinition/ISiKDiagnose

Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources"

Beispiele

Valides Minimalbeispiel Prozedur:

<Procedure xmlns="http://hl7.org/fhir">
    <id value="procedure" />
    <meta>
        <profile value="https://gematik.de/fhir/ISiK/StructureDefinition/ISiKProzedur" />
    </meta>
    <status value="completed" />
    <category>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="387713003" />
            <display value="Surgical procedure (procedure)" />
        </coding>
    </category>
    <code>
        <coding>
            <system value="http://snomed.info/sct" />
            <code value="80146002" />
            <display value="Excision of appendix (procedure)" />
        </coding>
        <coding>
            <system value="http://fhir.de/CodeSystem/bfarm/ops" />
            <version value="2020" />
            <code value="5-470" />
            <display value="Appendektomie" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/patient" />
    </subject>
    <performedDateTime value="2020-04-23" />
</Procedure>