HSAI FHIR Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: CDT Procedure

Procedure profile created by the Clinical Data Transformer (CDT) tool for international use

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
Slices for extension		3..*	Extension	Extension Slice: Unordered, Open by value:url
extension:textSource	S	1..1	string	Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart	S	1..1	integer	Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd	S	1..1	integer	Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
identifier	S	1..*	Identifier	External Identifiers for this procedure
system		0..1	uri	The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value		1..1	string	The value that is unique
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
value		0..1	string	Primitive value for code Required Pattern: completed
code	S	1..1	CodeableConcept	Identification of the procedure Binding: CDT Procedure Value Set (required)
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://snomed.info/sct
version		1..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
subject	S	1..1	Reference(Patient | Group)	Who the procedure was performed on
performed[x]	S	0..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
bodySite	S	0..1	CodeableConcept	Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	required	CDTProcedureVS https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-procedure-vs from this IG
Procedure.bodySite	required	CDTBodySideValueSet https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs from this IG

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		3..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textSource	S	1..1	string	Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexStart	S	1..1	integer	Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexEnd	S	1..1	integer	Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
system	Σ	0..1	uri	The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value	Σ	1..1	string	The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
value		0..1	string	Primitive value for code Required Pattern: completed
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: CDT Procedure Value Set (required) ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient | Group)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
performed[x]	SΣ	0..1		When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performedPeriod			Period
bodySite	SΣ	0..1	CodeableConcept	Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	required	CDTProcedureVS https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-procedure-vs from this IG
Procedure.bodySite	required	CDTBodySideValueSet https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		3..*	Extension	Extension Slice: Unordered, Open by value:url
extension:textSource	S	1..1	string	Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart	S	1..1	integer	Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd	S	1..1	integer	Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (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	0..1	uri	The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
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(Organization)	Organization that issued id (may be just text)
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional content defined by implementations
value		0..1	string	Primitive value for code Required Pattern: completed
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: CDT Procedure Value Set (required)
id		0..1	string	Unique id for inter-element referencing
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	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://snomed.info/sct
version	Σ	1..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(Patient | Group)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	0..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed
bodySite	SΣ	0..1	CodeableConcept	Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Procedure.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	required	CDTProcedureVS https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-procedure-vs from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	required	CDTBodySideValueSet https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs from this IG
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Procedure

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 9 elements

Extensions

This structure refers to these extensions:

• https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
• https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
• https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
Slices for extension		3..*	Extension	Extension Slice: Unordered, Open by value:url
extension:textSource	S	1..1	string	Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart	S	1..1	integer	Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd	S	1..1	integer	Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
identifier	S	1..*	Identifier	External Identifiers for this procedure
system		0..1	uri	The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value		1..1	string	The value that is unique
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
value		0..1	string	Primitive value for code Required Pattern: completed
code	S	1..1	CodeableConcept	Identification of the procedure Binding: CDT Procedure Value Set (required)
coding
system		1..1	uri	Identity of the terminology system Required Pattern: http://snomed.info/sct
version		1..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system
display		1..1	string	Representation defined by the system
subject	S	1..1	Reference(Patient | Group)	Who the procedure was performed on
performed[x]	S	0..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
bodySite	S	0..1	CodeableConcept	Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	required	CDTProcedureVS https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-procedure-vs from this IG
Procedure.bodySite	required	CDTBodySideValueSet https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		3..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textSource	S	1..1	string	Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexStart	S	1..1	integer	Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:textIndexEnd	S	1..1	integer	Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure ele-1: All FHIR elements must have a @value or children
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children
system	Σ	0..1	uri	The namespace for the identifier value ele-1: All FHIR elements must have a @value or children Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
value	Σ	1..1	string	The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
value		0..1	string	Primitive value for code Required Pattern: completed
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: CDT Procedure Value Set (required) ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient | Group)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
performed[x]	SΣ	0..1		When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
performedPeriod			Period
bodySite	SΣ	0..1	CodeableConcept	Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.code	required	CDTProcedureVS https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-procedure-vs from this IG
Procedure.bodySite	required	CDTBodySideValueSet https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		3..*	Extension	Extension Slice: Unordered, Open by value:url
extension:textSource	S	1..1	string	Text Source Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
extension:textIndexStart	S	1..1	integer	Text Index Start Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
extension:textIndexEnd	S	1..1	integer	Text Index End Extension URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (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	0..1	uri	The namespace for the identifier value Required Pattern: https://cdt-beta.healthsage.ai/fhir/identifier/hsai-cdt
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(Organization)	Organization that issued id (may be just text)
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional content defined by implementations
value		0..1	string	Primitive value for code Required Pattern: completed
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SΣ	1..1	CodeableConcept	Identification of the procedure Binding: CDT Procedure Value Set (required)
id		0..1	string	Unique id for inter-element referencing
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	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://snomed.info/sct
version	Σ	1..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(Patient | Group)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	0..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	Σ	0..*	Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)	The justification that the procedure was performed
bodySite	SΣ	0..1	CodeableConcept	Body site laterality (left, right, bilateral) Binding: CDT Body Side Value Set (required)
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Manipulated, implanted, or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
Procedure.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	required	CDTProcedureVS https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-procedure-vs from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	required	CDTBodySideValueSet https://cdt-beta.healthsage.ai/fhir/ValueSet/cdt-body-side-vs from this IG
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Procedure

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 9 elements

Extensions

This structure refers to these extensions:

• https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-source
• https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-start
• https://cdt-beta.healthsage.ai/fhir/StructureDefinition/text-index-end

Other representations of profile: CSV, Excel, Schematron