Procedure

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. Refer to the US Core Procedure profile.

Schema

Elements

Name	Required	Type	Description
identifier		Identifier[]	External Identifiers for this procedure Details Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. This is a business identifier, not a resource identifier (see [discussion](resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.
instantiatesCanonical		canonical[]	Instantiates FHIR protocol or definition Details The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.
instantiatesUri		uri[]	Instantiates external protocol or definition Details The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.
basedOn		Reference<CarePlan | ServiceRequest>[]	A request for this procedure Details A reference to a resource that contains details of the request for this procedure.
partOf		Reference< Procedure | Observation | MedicationAdministration >[]	Part of referenced event Details A larger event of which this particular procedure is a component or step. The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).
status	✓	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Details A code specifying the state of the procedure. Generally, this will be the in-progress or completed state. The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
statusReason		CodeableConcept	Reason for current status Details Captures the reason for the current state of the procedure. This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.
category		CodeableConcept	Classification of the procedure Details A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").
code		CodeableConcept	Identification of the procedure Details The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
subject	✓	Reference<Patient | Group>	Who the procedure was performed on Details The person, animal or group on which the procedure was performed.
encounter		Reference<Encounter>	Encounter created as part of Details The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
performed[x]		dateTime, Period, string, Age, Range	When the procedure was performed Details Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured. Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.
recorder		Reference< Patient | RelatedPerson | Practitioner | PractitionerRole >	Who recorded the procedure Details Individual who recorded the record and takes responsibility for its content.
asserter		Reference< Patient | RelatedPerson | Practitioner | PractitionerRole >	Person who asserts this procedure Details Individual who is making the procedure statement.
performer		ProcedurePerformer[]	The people who performed the procedure Details Limited to "real" people rather than equipment.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
function		CodeableConcept	Type of performance Details Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.
actor	✓	Reference< Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device >	The reference to the practitioner Details The practitioner who was involved in the procedure.
onBehalfOf		Reference<Organization>	Organization the device or practitioner was acting for Details The organization the device or practitioner was acting on behalf of.
location		Reference<Location>	Where the procedure happened Details The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
reasonCode		CodeableConcept[]	Coded reason procedure performed Details The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
reasonReference		Reference< Condition | Observation | Procedure | DiagnosticReport | DocumentReference >[]	The justification that the procedure was performed Details The justification of why the procedure was performed. It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.
bodySite		CodeableConcept[]	Target body sites Details Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension [procedure-targetbodystructure](extension-procedure-targetbodystructure.html).
outcome		CodeableConcept	The result of procedure Details The outcome of the procedure - did it resolve the reasons for the procedure being performed? If outcome contains narrative text only, it can be captured using the CodeableConcept.text.
report		Reference< DiagnosticReport | DocumentReference | Composition >[]	Any report resulting from the procedure Details This could be a histology result, pathology report, surgical report, etc. There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.
complication		CodeableConcept[]	Complication following the procedure Details Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues. If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.
complicationDetail		Reference<Condition>[]	A condition that is a result of the procedure Details Any complications that occurred during the procedure, or in the immediate post-performance period.
followUp		CodeableConcept[]	Instructions for follow up Details If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.
note		Annotation[]	Additional information about the procedure Details Any other notes and comments about the procedure.
focalDevice		ProcedureFocalDevice[]	Manipulated, implanted, or removed device Details A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
action		CodeableConcept	Kind of change to device Details The kind of change that happened to the device during the procedure.
manipulated	✓	Reference<Device>	Device that was changed Details The device that was manipulated (changed) during the procedure.
usedReference		Reference< Device | Medication | Substance >[]	Items used during procedure Details Identifies medications, devices and any other substance used as part of the procedure. For devices actually implanted or removed, use Procedure.device.
usedCode		CodeableConcept[]	Coded items used during the procedure Details Identifies coded items that were used as part of the procedure. For devices actually implanted or removed, use Procedure.device.

Search Parameters

Name	Type	Description	Expression
code	token	A code to identify a procedure	Procedure.code
date	date	When the procedure was performed	Procedure.performed
identifier	token	A unique identifier for a procedure	Procedure.identifier
patient	reference	Search by subject - a patient	Procedure.subject.where(resolve() is Patient)
encounter	reference	Encounter created as part of	Procedure.encounter
based-on	reference	A request for this procedure	Procedure.basedOn
category	token	Classification of the procedure	Procedure.category
instantiates-canonical	reference	Instantiates FHIR protocol or definition	Procedure.instantiatesCanonical
instantiates-uri	uri	Instantiates external protocol or definition	Procedure.instantiatesUri
location	reference	Where the procedure happened	Procedure.location
part-of	reference	Part of referenced event	Procedure.partOf
performer	reference	The reference to the practitioner	Procedure.performer.actor
reason-code	token	Coded reason procedure performed	Procedure.reasonCode
reason-reference	reference	The justification that the procedure was performed	Procedure.reasonReference
status	token	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown	Procedure.status
subject	reference	Search by subject	Procedure.subject

Inherited Elements

Name	Required	Type	Description
id		string	Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta		Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules		uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language		code	Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text		Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
contained		Resource[]	Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Usage

Procedure is one of the event resources in the FHIR workflow specification.

This resource is used to record the details of current and historical procedures performed on or for a patient. A procedure is an activity that is performed on, with, or for a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise, etc. Procedures may be performed by a healthcare professional, a service provider, a friend or relative or in some cases by the patient themselves.

This resource provides summary information about the occurrence of the procedure and is not intended to provide real-time snapshots of a procedure as it unfolds, though for long-running procedures such as psychotherapy, it could represent summary level information about overall progress. The creation of a resource to support detailed real-time procedure information awaits the identification of a specific implementation use-case to share such information.

Relationships

The Procedure resource should not be used to capture an event if a more specific resource already exists - i.e. immunizations, drug administrations and communications. The boundary between determining whether an action is a Procedure (training or counseling) as opposed to a Communication is based on whether there's a specific intent to change the mind-set of the patient. Mere disclosure of information would be considered a Communication. A process that involves verification of the patient's comprehension or to change the patient's mental state would be a Procedure.

Note that many diagnostic processes are procedures that generate Observations and DiagnosticReports. In many cases, such an observation does not require an explicit representation of the procedure used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the Procedure resource is used to describe the activity.

Some diagnostic procedures might not have a Procedure record. The Procedure record is only necessary when there is a need to capture information about the physical intervention that was performed to capture the diagnostic information (e.g. anesthetic, incision, scope size, etc.)

A Task is a workflow step such as cancelling an order, fulfilling an order, signing an order, merging a set of records, admitting a patient. Procedures are actions that are intended to result in a physical or mental change to or for the subject (e.g. surgery, physiotherapy, training, counseling). A Task resource often exists in parallel with clinical resources. For example, a Task might request fulfillment of a ServiceRequest ordering a Procedure.

Referenced By

• AdverseEvent
• Appointment
• ChargeItem
• Claim
• DeviceUseStatement
• Encounter
• ExplanationOfBenefit
• Flag
• ImagingStudy
• MedicationAdministration
• MedicationDispense
• MedicationStatement
• Observation
• QuestionnaireResponse