HSAI FHIR Implementation Guide
0.1.0 - CI Build Netherlands

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

## Resource Profile: CDT Procedure

Official URL: https://cdt-beta.healthsage.ai/fhir/StructureDefinition/cdt-procedure | Version: 0.1.0
Active as of 2026-02-09 | Computable Name: CDTProcedure

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 | S Σ | 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 | ?!S Σ | 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 | S Σ | 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 | S Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
performed[x] | S Σ | 0..1 |  | When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
bodySite | S Σ | 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 | S Σ | 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 | ?!S Σ | 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 | S Σ | 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 | S Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
performed[x] | S Σ | 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 | S Σ | 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 | S Σ | 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 | ?!S Σ | 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 | S Σ | 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 | S Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
performed[x] | S Σ | 0..1 |  | When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
bodySite | S Σ | 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 | S Σ | 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 | ?!S Σ | 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 | S Σ | 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 | S Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of
performed[x] | S Σ | 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 | S Σ | 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