Interweave Implementation Guide
0.1.0 - ci-build
Interweave Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the R4 profiles here.
Official URL: https://fhir.yhcr.nhs.uk/StructureDefinition/Interweave-Procedure | Version: 0.1.0 | |||
Active as of 2024-07-17 | Computable Name: InterweaveProcedure |
Interweave Procedure resource profile.
Status: Active: Approved (STU)
This profile sets minimum expectations for the Procedure resource.
As described further in the FHIR documentation, a Procedure should be used to describe something that is actually done to a Patient. There are other FHIR Resources which are more appropriate for observations, assessments, opinions etc.
It is also noted that a pragmatic approach is needed to specifying mandatory fields for this resource. The reality is that it may often be populated from a “clinical coding” system - that does not necessarily have access to the full contextual richness that might ideally be hoped for.
The following mandatory fields are defined in order to properly describe a Procedure:
Subject - every Procedure must be linked to a Patient (not a Group)
In addition the following fields are “Must Support” - ie they must be populated if relevant and known:
Identifier - a Local Id should be provided, such that could be quoted if manually getting in touch to find out more
Category - A simple and short list of SNOMED codes to describe the overall category of procedure eg “Surgical Procedure”, “Diagnostic Procedure”. We pre-adopt the R4 list which adds one extra code for “Social Service Procedure”.
Context - A reference to the Encounter where the procedure was performed. This is likely to be very useful and should be provided if at all possible. (Noting however the introductory comments that this may be impossible if the linkage is lost within a clinical coding system). Should link to the lowest level possible in any hierarchy, thus providing maximum detail about where the condition was noted
Note: Do not link to an Episode of Care, as this is deprecated in FHIR R4
Performed - when the Procedure was performed. We have removed the DateTime data type from this field as Period.start would provide identical data, and it reduced the complexity of processing multiple data types for the data consumer.
Body Site - Useful to populate if known.
Outcome - A short and simple list of “successful”, “unsuccessful”, “partially successful”. Must be populated when relevant and known. (Accepting that for some types of procedure then this may be impossible if there is no simple definition of “success”)
Focal Device - This is useful to provide if relevant (ie if a device has been implanted, changed or removed). May inform community teams with follow up care.
notDoneReason - relevent with status codes such as “suspended” or “aborted” to provide reason for suspension / aborting the procedure. In R4, this field has been renamed to StatusReason.
Other fields are optional and may be populated if known - on the understanding that not all data consumers will necessarily make use of them. For a Procedure there are many of these optional fields. This reflects the view expressed in the introduction that there is considerable richness which could be added, but which it is not necessarily realistic to insist on. Points of note include:
Location - Generally speaking the exact location where the procedure was performed seems unlikely to be vital for a regional care record. The organisation involved (from the Provenance tags) is often likely to be sufficient, and further details can also be provided by the Context linking to an Encounter.
Reason Code and Reason Reference - Could be useful to provide a code and/or a link to a Condition or Observation to explain the reason for the Procedure
Report - Could be useful if relevant to provide additional background information
Complication and Complication Detail - can be populated with a code and/or Condition reference for any complications if relevant and known
Used Code and Used Reference - Relevant to stock control within an organisation, but less so for a regional record
Note - Only to be used with caution. Any notes may be shared widely across the region, including being viewed by the patient themselves
Anaesthetic Issues (Care Connect Extension) - May be risky if not consistently used. Consider using AllergyIntolerance or AdverseEvent instead.
Definition – Removed.
Based On – Removed.
Part Of – Removed.
Not Done - Somewhat overlaps with status codes such as “suspended” or “aborted”, but provides the possibility of adding additional coding to explain why. (Note: FHIR R4 concurs, and remodels this into a single field called “Status Reason”). Inline with R4, we have added StatusReason field.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CareConnect-Procedure-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | CareConnect-Procedure-1 | An action that is being or was performed on a patient | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
extension:anaestheticIssues | 0..1 | Extension-CareConnect-AnaestheticIssues-1 | DISCOURAGED: May be risky if not consistently used. Consider using AllergyIntolerance or AdverseEvent instead. | |
Slices for identifier | 0..* | Identifier | External Identifiers for this procedure Slice: Unordered, Open by value:system | |
identifier:localIdentifier | S | 0..1 | Identifier | External Identifiers for this procedure |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-procedure-identifier |
value | S | 1..1 | string | The Local procedure Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
definition | 0..0 | |||
basedOn | 0..0 | |||
partOf | 0..0 | |||
status | S | 1..1 | code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown |
notDone | 0..0 | |||
notDoneReason | S | 0..1 | CodeableConcept | Reason procedure was not performed Binding: Procedure Not Performed Reason (SNOMED-CT) (preferred) |
category | S | 0..1 | CodeableConcept | Classification of the procedure Binding: Interweave R4 Procedure Category Code (required) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
code | S | 1..1 | CodeableConcept | Identification of the procedure Binding: Interweave UkCore Procedure Code (required) |
coding | 1..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
coding:snomedCT | S | 1..1 | Coding | Code defined by a terminology system Binding: Interweave UkCore Procedure Code (required) |
subject | S | 1..1 | Reference(CareConnectPatient1) | Who the procedure was performed on. (A patient, NOT group) |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
context | S | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode associated with the procedure |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
performed[x] | S | 1..1 | Period | Date/Period the procedure was performed |
start | S | 1..1 | dateTime | Starting time with inclusive boundary |
performer | ||||
role | 0..1 | CodeableConcept | The role the actor was in Binding: Procedure Performer Role Codes (preferred) | |
reasonCode | 0..* | CodeableConcept | Coded reason procedure performed Binding: Procedure Reason Codes (preferred) | |
bodySite | S | 0..1 | CodeableConcept | Target body sites Binding: SNOMED CT Body Structures (required) |
outcome | S | 0..1 | CodeableConcept | The result of procedure Binding: Procedure Outcome Codes (SNOMED CT) (required) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/Diagnosis Codes (preferred) | |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: Procedure Follow up Codes (SNOMED CT) (preferred) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
note | 0..* | Annotation | Additional information about the Procedure. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |
focalDevice | S | 0..* | BackboneElement | Device changed in procedure |
action | 0..1 | CodeableConcept | Kind of change to device Binding: Procedure Device Action Codes (preferred) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
manipulated | S | 1..1 | Reference(Device) | Device that was changed |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIR Device Types (preferred) | |
Documentation for this format |
Path | Conformance | ValueSet |
Procedure.notDoneReason | preferred | Procedure Not Performed Reason (SNOMED-CT) |
Procedure.category | required | Interweave R4 Procedure Category Code |
Procedure.code | required | Interweave UkCore Procedure Code |
Procedure.code.coding:snomedCT | required | Interweave UkCore Procedure Code |
Procedure.performer.role | preferred | Procedure Performer Role Codes |
Procedure.reasonCode | preferred | Procedure Reason Codes |
Procedure.bodySite | required | SNOMED CT Body Structures |
Procedure.outcome | required | Procedure Outcome Codes (SNOMED CT) |
Procedure.complication | preferred | Condition/Problem/Diagnosis Codes |
Procedure.followUp | preferred | Procedure Follow up Codes (SNOMED CT) |
Procedure.focalDevice.action | preferred | Procedure Device Action Codes |
Procedure.usedCode | preferred | FHIR Device Types |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | C | 0..* | CareConnect-Procedure-1 | An action that is being or was performed on a patient | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
anaestheticIssues | 0..1 | CodeableConcept, Reference(CareConnect-Condition-1) | DISCOURAGED: May be risky if not consistently used. Consider using AllergyIntolerance or AdverseEvent instead. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-AnaestheticIssues-1 Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | External Identifiers for this procedure Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | External Identifiers for this procedure | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-procedure-identifier | ||||
value | SΣ | 1..1 | string | The Local procedure Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
notDoneReason | SΣC | 0..1 | CodeableConcept | Reason procedure was not performed Binding: Procedure Not Performed Reason (SNOMED-CT) (preferred) | ||||
category | SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: Interweave R4 Procedure Category Code (required) | ||||
code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Interweave UkCore Procedure Code (required) | ||||
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | SΣ | 1..1 | Coding | Code defined by a terminology system Binding: Interweave UkCore Procedure Code (required) | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | Who the procedure was performed on. (A patient, NOT group) | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode associated with the procedure | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
performed[x] | SΣ | 1..1 | Period | Date/Period the procedure was performed | ||||
start | SΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Procedure Reason Codes (preferred) | ||||
bodySite | SΣ | 0..1 | CodeableConcept | Target body sites Binding: SNOMED CT Body Structures (required) | ||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (extensible): A code from the SNOMED Clinical Terminology UK. | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
outcome | SΣ | 0..1 | CodeableConcept | The result of procedure Binding: Procedure Outcome Codes (SNOMED CT) (required) | ||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/Diagnosis Codes (preferred) | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK. | ||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: Procedure Follow up Codes (SNOMED CT) (preferred) | |||||
note | 0..* | Annotation | Additional information about the Procedure. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |||||
text | 1..1 | string | The annotation - text content | |||||
focalDevice | S | 0..* | BackboneElement | Device changed in procedure | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: Procedure Device Action Codes (preferred) | |||||
manipulated | S | 1..1 | Reference(Device) | Device that was changed | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIR Device Types (preferred) | |||||
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
dom-1 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
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 : contained.where(('#'+id in %resource.descendants().reference).not()).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() | |
ele-1 | error | Procedure.extension:anaestheticIssues, Procedure.focalDevice | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | Procedure.extension:anaestheticIssues | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
pro-1 | error | Procedure | Reason not done is only permitted if notDone indicator is true : notDoneReason.empty() or notDone = true |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Procedure | C | 0..* | CareConnect-Procedure-1 | An action that is being or was performed on a patient | ||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: Common Tags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones" | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: Common Languages (extensible): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
anaestheticIssues | 0..1 | CodeableConcept, Reference(CareConnect-Condition-1) | DISCOURAGED: May be risky if not consistently used. Consider using AllergyIntolerance or AdverseEvent instead. URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-AnaestheticIssues-1 Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | External Identifiers for this procedure Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 1..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | External Identifiers for this procedure | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-procedure-identifier | ||||
value | SΣ | 1..1 | string | The Local procedure Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
assigner | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization that issued id (may be just text) | ||||
status | ?!SΣ | 1..1 | code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
notDoneReason | SΣC | 0..1 | CodeableConcept | Reason procedure was not performed Binding: Procedure Not Performed Reason (SNOMED-CT) (preferred) | ||||
category | SΣ | 0..1 | CodeableConcept | Classification of the procedure Binding: Interweave R4 Procedure Category Code (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Interweave UkCore Procedure Code (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:snomedCT | SΣ | 1..1 | Coding | Code defined by a terminology system Binding: Interweave UkCore Procedure Code (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | SΣ | 1..1 | Reference(CareConnectPatient1) | Who the procedure was performed on. (A patient, NOT group) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
context | SΣ | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode associated with the procedure | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
performed[x] | SΣ | 1..1 | Period | Date/Period the procedure was performed | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
start | SΣC | 1..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
role | Σ | 0..1 | CodeableConcept | The role the actor was in Binding: Procedure Performer Role Codes (preferred) | ||||
actor | Σ | 1..1 | Reference(RelatedPerson | Device | CareConnect-Organization-1 | CareConnectPatient1 | CareConnect-Practitioner-1) | The reference to the practitioner | ||||
onBehalfOf | 0..1 | Reference(CareConnect-Organization-1) | Organization the device or practitioner was acting for | |||||
location | Σ | 0..1 | Reference(CareConnect-Location-1) | Where the procedure happened | ||||
reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Procedure Reason Codes (preferred) | ||||
reasonReference | Σ | 0..* | Reference(CareConnect-Observation-1 | CareConnect-Condition-1) | Condition that is the reason the procedure performed | ||||
bodySite | SΣ | 0..1 | CodeableConcept | Target body sites Binding: SNOMED CT Body Structures (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Body Site (extensible): A code from the SNOMED Clinical Terminology UK. | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
outcome | SΣ | 0..1 | CodeableConcept | The result of procedure Binding: Procedure Outcome Codes (SNOMED CT) (required) | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
report | 0..* | Reference(DiagnosticReport) | Any report resulting from the procedure | |||||
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/Diagnosis Codes (preferred) | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:snomedCT | Σ | 0..1 | Coding | Code defined by a terminology system Binding: Care Connect Condition Code (required): A code from the SNOMED Clinical Terminology UK. | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
snomedCTDescriptionID | 0..* | (Complex) | The SNOMED CT Description ID for the display URL: https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-coding-sctdescid | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
complicationDetail | 0..* | Reference(CareConnect-Condition-1) | A condition that is a result of the procedure | |||||
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: Procedure Follow up Codes (SNOMED CT) (preferred) | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
note | 0..* | Annotation | Additional information about the Procedure. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
author[x] | Σ | 0..1 | Individual responsible for the annotation | |||||
authorReference | Reference(RelatedPerson | CareConnectPatient1 | CareConnect-Practitioner-1) | |||||||
authorString | string | |||||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | 1..1 | string | The annotation - text content | |||||
focalDevice | S | 0..* | BackboneElement | Device changed in procedure | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
action | 0..1 | CodeableConcept | Kind of change to device Binding: Procedure Device Action Codes (preferred) | |||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
manipulated | S | 1..1 | Reference(Device) | Device that was changed | ||||
id | 0..1 | string | xml:id (or equivalent in JSON) | |||||
extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
usedReference | 0..* | Reference(Device | Substance | CareConnect-Medication-1) | Items used during procedure | |||||
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIR Device Types (preferred) | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Procedure.meta.security | extensible | All Security Labels | ||||
Procedure.meta.tag | example | Common Tags | ||||
Procedure.meta.tag:Source | example | Common Tags | ||||
Procedure.meta.tag:Provenance | example | Common Tags | ||||
Procedure.language | extensible | Common Languages
| ||||
Procedure.identifier.use | required | IdentifierUse | ||||
Procedure.identifier.type | extensible | Identifier Type Codes | ||||
Procedure.identifier:localIdentifier.use | required | IdentifierUse | ||||
Procedure.identifier:localIdentifier.type | extensible | Identifier Type Codes | ||||
Procedure.status | required | EventStatus | ||||
Procedure.notDoneReason | preferred | Procedure Not Performed Reason (SNOMED-CT) | ||||
Procedure.category | required | Interweave R4 Procedure Category Code | ||||
Procedure.code | required | Interweave UkCore Procedure Code | ||||
Procedure.code.coding:snomedCT | required | Interweave UkCore Procedure Code | ||||
Procedure.performer.role | preferred | Procedure Performer Role Codes | ||||
Procedure.reasonCode | preferred | Procedure Reason Codes | ||||
Procedure.bodySite | required | SNOMED CT Body Structures | ||||
Procedure.bodySite.coding:snomedCT | extensible | Care Connect Body Site | ||||
Procedure.outcome | required | Procedure Outcome Codes (SNOMED CT) | ||||
Procedure.complication | preferred | Condition/Problem/Diagnosis Codes | ||||
Procedure.complication.coding:snomedCT | required | Care Connect Condition Code | ||||
Procedure.followUp | preferred | Procedure Follow up Codes (SNOMED CT) | ||||
Procedure.focalDevice.action | preferred | Procedure Device Action Codes | ||||
Procedure.usedCode | preferred | FHIR Device Types |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | Procedure.extension:anaestheticIssues, Procedure.performer, Procedure.focalDevice | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
ext-1 | error | Procedure.extension:anaestheticIssues | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CareConnect-Procedure-1
Summary
Mandatory: 10 elements (23 nested mandatory elements)
Must-Support: 26 elements
Fixed Value: 3 elements
Prohibited: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CareConnect-Procedure-1
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Procedure | 0..* | CareConnect-Procedure-1 | An action that is being or was performed on a patient | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | uri | Profiles this resource claims to conform to. Should list (i) this profile (ii) underlying CareConnect profile |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Source | |
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://yhcr.nhs.uk/Provenance | |
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
extension:anaestheticIssues | 0..1 | Extension-CareConnect-AnaestheticIssues-1 | DISCOURAGED: May be risky if not consistently used. Consider using AllergyIntolerance or AdverseEvent instead. | |
Slices for identifier | 0..* | Identifier | External Identifiers for this procedure Slice: Unordered, Open by value:system | |
identifier:localIdentifier | S | 0..1 | Identifier | External Identifiers for this procedure |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.yhcr.nhs.uk/Id/local-procedure-identifier |
value | S | 1..1 | string | The Local procedure Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
definition | 0..0 | |||
basedOn | 0..0 | |||
partOf | 0..0 | |||
status | S | 1..1 | code | preparation | in-progress | suspended | aborted | completed | entered-in-error | unknown |
notDone | 0..0 | |||
notDoneReason | S | 0..1 | CodeableConcept | Reason procedure was not performed Binding: Procedure Not Performed Reason (SNOMED-CT) (preferred) |
category | S | 0..1 | CodeableConcept | Classification of the procedure Binding: Interweave R4 Procedure Category Code (required) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
code | S | 1..1 | CodeableConcept | Identification of the procedure Binding: Interweave UkCore Procedure Code (required) |
coding | 1..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
coding:snomedCT | S | 1..1 | Coding | Code defined by a terminology system Binding: Interweave UkCore Procedure Code (required) |
subject | S | 1..1 | Reference(CareConnectPatient1) | Who the procedure was performed on. (A patient, NOT group) |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
context | S | 0..1 | Reference(CareConnect-Encounter-1) | Encounter or episode associated with the procedure |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
performed[x] | S | 1..1 | Period | Date/Period the procedure was performed |
start | S | 1..1 | dateTime | Starting time with inclusive boundary |
performer | ||||
role | 0..1 | CodeableConcept | The role the actor was in Binding: Procedure Performer Role Codes (preferred) | |
reasonCode | 0..* | CodeableConcept | Coded reason procedure performed Binding: Procedure Reason Codes (preferred) | |
bodySite | S | 0..1 | CodeableConcept | Target body sites Binding: SNOMED CT Body Structures (required) |
outcome | S | 0..1 | CodeableConcept | The result of procedure Binding: Procedure Outcome Codes (SNOMED CT) (required) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/Diagnosis Codes (preferred) | |
coding | 0..* | Coding | Code defined by a terminology system | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
followUp | 0..* | CodeableConcept | Instructions for follow up Binding: Procedure Follow up Codes (SNOMED CT) (preferred) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
note | 0..* | Annotation | Additional information about the Procedure. NB: Any notes may be shared widely across the region, including being viewed by the patient themselves | |
focalDevice | S | 0..* | BackboneElement | Device changed in procedure |
action | 0..1 | CodeableConcept | Kind of change to device Binding: Procedure Device Action Codes (preferred) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
manipulated | S | 1..1 | Reference(Device) | Device that was changed |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIR Device Types (preferred) | |
Documentation for this format |
Path | Conformance | ValueSet |
Procedure.notDoneReason | preferred | Procedure Not Performed Reason (SNOMED-CT) |
Procedure.category | required | Interweave R4 Procedure Category Code |
Procedure.code | required | Interweave UkCore Procedure Code |
Procedure.code.coding:snomedCT | required | Interweave UkCore Procedure Code |
Procedure.performer.role | preferred | Procedure Performer Role Codes |
Procedure.reasonCode | preferred | Procedure Reason Codes |
Procedure.bodySite | required | SNOMED CT Body Structures |
Procedure.outcome | required | Procedure Outcome Codes (SNOMED CT) |