CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
3.0.0 - Release 3 - draft
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
3.0.0 - Release 3 - draft
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v3.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-daily-procedure | Version: 3.0.0 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: AcuteCareHospitalDailyEventProcedure | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.1002.42.9 | ||||
This profile contains Required and Must Support data elements for reporting transmission-based precaution procedure information for the NHSN Acute Care Hospital (ACH) Daily Digital Quality Measure. This profile inherits from the US Core 6.1.0 Procedure profile and applies capabilities from the QI Core 6.0.0 Procedure profile and QI Core 6.0.0 Procedure Not Done profile.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 1.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type |
Description & Constraints Filter: 
|
|---|---|---|---|---|
  Procedure
|
C | 0..* | USCoreProcedureProfile(6.1.0) | An action that is being or was performed on a patient Constraints: us-core-7 |
  id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
implicitRules
|
0..1 | uri | A set of rules under which this content was created | |
  Slices for extension
|
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|
   extension:recorded
|
0..1 | dateTime | (QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
|
 modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|
 basedOn
|
0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (QI-Core)(USCDI) A request for this procedure |
|
|
status
|
C | 1..1 | code |
(NHSN-MS) (QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknownBinding: EventStatus (required) |
 statusReason
|
0..1 | CodeableConcept | (QI-Core) Reason for the current status Binding: QICore Negation Reason Codes (extensible) |
|
|
category
|
0..1 | CodeableConcept | 'Surgical Procedure' | 'Diagnostic procedure' Binding: Procedure Category ValueSet (required) |
|
|
code
|
C | 1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Identification of the procedureBinding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure Constraints: not-done-extension-present |
  Slices for extension
|
Content/Rules for all slices | |||
 extension:notDoneValueSet
|
0..1 | canonical(ValueSet) | (QI-Core) What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
|
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) Who the procedure was performed on |
|
 reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Encounter during which the procedure was performed |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
 performed[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) When the procedure was performed |
|
|
performedDateTime
|
dateTime | |||
|
performedPeriod
|
Period | |||
|
location
|
0..1 | Reference(Location) {b} |
(NHSN-MS) (QI-Core)(USCDI) Where the procedure was performed |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
reasonCode
|
0..* | CodeableConcept | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service Binding: ProcedureReasonCodes (preferred) |
|
|
reasonReference
|
0..* | Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile(6.1.0)) | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service |
|
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📦4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | extensible | QICore Negation Reason Codes | 📦6.0.0 | QI-Core Implementation Guide v6.0 |
| Procedure.category | Base | required | Procedure Category ValueSet | 📦3.0.0 | This IG |
| Procedure.code | Base | extensible | US Core Procedure Codes | 📍6.1.0 | US Core v6.1 |
| Procedure.reasonCode | Base | preferred | Procedure Reason Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| not-done-extension-present | error | Procedure.code | qicore-notDoneValueSet extension does not exist |
extension.where(url='http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists().not()
|
| us-core-7 | error | Procedure | Performed SHALL be present if the status is 'completed' or 'in-progress' |
(status='completed' or status='in-progress') implies performed.exists()
|
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
Procedure
|
0..* | USCoreProcedureProfile(6.1.0) | An action that is being or was performed on a patient | |
 id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
meta
|
||||
|
Slices for extension
|
Content/Rules for all slices | |||
|
extension:link-received-date-extension
|
0..1 | dateTime |
Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|
|
Slices for extension
|
0..* | Extension |
Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|
|
extension:recorded
|
0..1 | dateTime | (QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
|
|
basedOn
|
0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (QI-Core)(USCDI) A request for this procedure | |
|
status
|
1..1 | code | (NHSN-MS)(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | |
|
statusReason
|
0..1 | CodeableConcept | (QI-Core) Reason for the current status Binding: QICore Negation Reason Codes (extensible) |
|
|
category
|
0..1 | CodeableConcept | 'Surgical Procedure' | 'Diagnostic procedure' Binding: Procedure Category ValueSet (required) |
|
|
code
|
C | 1..1 | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Identification of the procedure Constraints: not-done-extension-present |
|
Slices for extension
|
Content/Rules for all slices | |||
|
extension:notDoneValueSet
|
0..1 | canonical(ValueSet) | (QI-Core) What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
|
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} | (NHSN-MS)(QI-Core)(USCDI) Who the procedure was performed on | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Encounter during which the procedure was performed |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
performed[x]
|
0..1 | (NHSN-MS)(QI-Core)(USCDI) When the procedure was performed | ||
|
performedDateTime
|
dateTime | |||
|
performedPeriod
|
Period | |||
|
location
|
0..1 | Reference(Location) {b} |
(NHSN-MS) (QI-Core)(USCDI) Where the procedure was performed |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
reasonCode
|
0..* | CodeableConcept | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service Binding: ProcedureReasonCodes (preferred) |
|
|
reasonReference
|
0..* | Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile(6.1.0)) | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service | |
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.statusReason | Base | extensible | QICore Negation Reason Codes | 📦6.0.0 | QI-Core Implementation Guide v6.0 |
| Procedure.category | Base | required | Procedure Category ValueSet | 📦3.0.0 | This IG |
| Procedure.reasonCode | Base | preferred | Procedure Reason Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| not-done-extension-present | error | Procedure.code | qicore-notDoneValueSet extension does not exist |
extension.where(url='http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists().not()
|
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
||||
|---|---|---|---|---|---|---|---|---|
|
Procedure
|
C | 0..* | USCoreProcedureProfile(6.1.0) | An action that is being or was performed on a patient Constraints: us-core-7 |
||||
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|||||
|
meta
|
0..1 | Meta | Metadata about the resource | |||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
Slices for extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
extension:link-received-date-extension
|
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|||||
|
versionId
|
0..1 | id | Version specific identifier | |||||
|
lastUpdated
|
0..1 | instant | When the resource version last changed | |||||
|
source
|
0..1 | uri | Identifies where the resource comes from | |||||
|
profile
|
0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
|||||
|
security
|
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
|||||
|
tag
|
0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
|||||
|
implicitRules
|
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.
|
|||||
|
text
|
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements |
|||||
|
contained
|
0..* | Resource | Contained, inline Resources |
|||||
|
Slices for extension
|
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|||||
|
extension:recorded
|
0..1 | dateTime | (QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
|||||
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|||||
|
identifier
|
0..* | Identifier | External Identifiers for this procedure |
|||||
|
instantiatesCanonical
|
0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
|||||
|
instantiatesUri
|
0..* | uri | Instantiates external protocol or definition |
|||||
|
basedOn
|
0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (QI-Core)(USCDI) A request for this procedure |
|||||
|
partOf
|
0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event |
|||||
|
status
|
C | 1..1 | code |
(NHSN-MS) (QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknownBinding: EventStatus (required) |
||||
|
statusReason
|
0..1 | CodeableConcept | (QI-Core) Reason for the current status Binding: QICore Negation Reason Codes (extensible) |
|||||
|
category
|
0..1 | CodeableConcept | 'Surgical Procedure' | 'Diagnostic procedure' Binding: Procedure Category ValueSet (required) |
|||||
|
code
|
C | 1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Identification of the procedureBinding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure Constraints: not-done-extension-present |
||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
Slices for extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
extension:notDoneValueSet
|
0..1 | canonical(ValueSet) | (QI-Core) What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
|||||
|
coding
|
0..* | Coding | Code defined by a terminology system |
|||||
|
text
|
0..1 | string | Plain text representation of the concept | |||||
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) Who the procedure was performed on |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Encounter during which the procedure was performed |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
performed[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) When the procedure was performed |
|||||
|
performedDateTime
|
dateTime | |||||||
|
performedPeriod
|
Period | |||||||
|
recorder
|
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |||||
|
asserter
|
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |||||
|
performer
|
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
|
0..* | Extension | Extensions that cannot be ignored even if unrecognized |
|||||
|
function
|
0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. |
|||||
|
actor
|
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
|
0..1 | Reference(Location) {b} |
(NHSN-MS) (QI-Core)(USCDI) Where the procedure was performed |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
reasonCode
|
0..* | CodeableConcept | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service Binding: ProcedureReasonCodes (preferred) |
|||||
|
reasonReference
|
0..* | Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile(6.1.0)) | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service |
|||||
|
bodySite
|
0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
|||||
|
outcome
|
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
|
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
| ||||||||
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| not-done-extension-present | error | Procedure.code | qicore-notDoneValueSet extension does not exist |
extension.where(url='http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists().not()
|
| us-core-7 | error | Procedure | Performed SHALL be present if the status is 'completed' or 'in-progress' |
(status='completed' or status='in-progress') implies performed.exists()
|
This structure is derived from USCoreProcedureProfile
Summary
Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Key Elements View
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
Procedure
|
C | 0..* | USCoreProcedureProfile(6.1.0) | An action that is being or was performed on a patient Constraints: us-core-7 |
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
implicitRules
|
0..1 | uri | A set of rules under which this content was created | |
|
Slices for extension
|
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|
|
extension:recorded
|
0..1 | dateTime | (QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
|
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|
|
basedOn
|
0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (QI-Core)(USCDI) A request for this procedure |
|
|
status
|
C | 1..1 | code |
(NHSN-MS) (QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknownBinding: EventStatus (required) |
|
statusReason
|
0..1 | CodeableConcept | (QI-Core) Reason for the current status Binding: QICore Negation Reason Codes (extensible) |
|
|
category
|
0..1 | CodeableConcept | 'Surgical Procedure' | 'Diagnostic procedure' Binding: Procedure Category ValueSet (required) |
|
|
code
|
C | 1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Identification of the procedureBinding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure Constraints: not-done-extension-present |
|
Slices for extension
|
Content/Rules for all slices | |||
|
extension:notDoneValueSet
|
0..1 | canonical(ValueSet) | (QI-Core) What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
|
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) Who the procedure was performed on |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Encounter during which the procedure was performed |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
performed[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) When the procedure was performed |
|
|
performedDateTime
|
dateTime | |||
|
performedPeriod
|
Period | |||
|
location
|
0..1 | Reference(Location) {b} |
(NHSN-MS) (QI-Core)(USCDI) Where the procedure was performed |
|
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
reasonCode
|
0..* | CodeableConcept | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service Binding: ProcedureReasonCodes (preferred) |
|
|
reasonReference
|
0..* | Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile(6.1.0)) | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service |
|
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.status | Base | required | EventStatus | 📦4.0.1 | FHIR Std. |
| Procedure.statusReason | Base | extensible | QICore Negation Reason Codes | 📦6.0.0 | QI-Core Implementation Guide v6.0 |
| Procedure.category | Base | required | Procedure Category ValueSet | 📦3.0.0 | This IG |
| Procedure.code | Base | extensible | US Core Procedure Codes | 📍6.1.0 | US Core v6.1 |
| Procedure.reasonCode | Base | preferred | Procedure Reason Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| not-done-extension-present | error | Procedure.code | qicore-notDoneValueSet extension does not exist |
extension.where(url='http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists().not()
|
| us-core-7 | error | Procedure | Performed SHALL be present if the status is 'completed' or 'in-progress' |
(status='completed' or status='in-progress') implies performed.exists()
|
Differential View
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
|---|---|---|---|---|
|
Procedure
|
0..* | USCoreProcedureProfile(6.1.0) | An action that is being or was performed on a patient | |
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|
|
meta
|
||||
|
Slices for extension
|
Content/Rules for all slices | |||
|
extension:link-received-date-extension
|
0..1 | dateTime |
Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|
|
Slices for extension
|
0..* | Extension |
Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|
|
extension:recorded
|
0..1 | dateTime | (QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
|
|
basedOn
|
0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (QI-Core)(USCDI) A request for this procedure | |
|
status
|
1..1 | code | (NHSN-MS)(QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | |
|
statusReason
|
0..1 | CodeableConcept | (QI-Core) Reason for the current status Binding: QICore Negation Reason Codes (extensible) |
|
|
category
|
0..1 | CodeableConcept | 'Surgical Procedure' | 'Diagnostic procedure' Binding: Procedure Category ValueSet (required) |
|
|
code
|
C | 1..1 | CodeableConcept | (NHSN-MS)(QI-Core)(USCDI) Identification of the procedure Constraints: not-done-extension-present |
|
Slices for extension
|
Content/Rules for all slices | |||
|
extension:notDoneValueSet
|
0..1 | canonical(ValueSet) | (QI-Core) What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
|
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} | (NHSN-MS)(QI-Core)(USCDI) Who the procedure was performed on | |
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Encounter during which the procedure was performed |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
performed[x]
|
0..1 | (NHSN-MS)(QI-Core)(USCDI) When the procedure was performed | ||
|
performedDateTime
|
dateTime | |||
|
performedPeriod
|
Period | |||
|
location
|
0..1 | Reference(Location) {b} |
(NHSN-MS) (QI-Core)(USCDI) Where the procedure was performed |
|
|
reference
|
1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
|
|
reasonCode
|
0..* | CodeableConcept | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service Binding: ProcedureReasonCodes (preferred) |
|
|
reasonReference
|
0..* | Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile(6.1.0)) | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service | |
|
Documentation for this format
| ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.statusReason | Base | extensible | QICore Negation Reason Codes | 📦6.0.0 | QI-Core Implementation Guide v6.0 |
| Procedure.category | Base | required | Procedure Category ValueSet | 📦3.0.0 | This IG |
| Procedure.reasonCode | Base | preferred | Procedure Reason Codes | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| not-done-extension-present | error | Procedure.code | qicore-notDoneValueSet extension does not exist |
extension.where(url='http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists().not()
|
Snapshot View
| Name | Flags | Card. | Type |
Description & Constraints Filter:
|
||||
|---|---|---|---|---|---|---|---|---|
|
Procedure
|
C | 0..* | USCoreProcedureProfile(6.1.0) | An action that is being or was performed on a patient Constraints: us-core-7 |
||||
|
id
|
1..1 | id |
(NHSN-MS) Logical id of this artifact |
|||||
|
meta
|
0..1 | Meta | Metadata about the resource | |||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
Slices for extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
extension:link-received-date-extension
|
0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension |
|||||
|
versionId
|
0..1 | id | Version specific identifier | |||||
|
lastUpdated
|
0..1 | instant | When the resource version last changed | |||||
|
source
|
0..1 | uri | Identifies where the resource comes from | |||||
|
profile
|
0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
|||||
|
security
|
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
|||||
|
tag
|
0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
|||||
|
implicitRules
|
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.
|
|||||
|
text
|
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements |
|||||
|
contained
|
0..* | Resource | Contained, inline Resources |
|||||
|
Slices for extension
|
0..* | Extension | Extension Slice: Unordered, Open by value:url Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them |
|||||
|
extension:recorded
|
0..1 | dateTime | (QI-Core) When the procedure was first captured in the subject's record URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded |
|||||
|
modifierExtension
|
0..* | Extension | Extensions that cannot be ignored |
|||||
|
identifier
|
0..* | Identifier | External Identifiers for this procedure |
|||||
|
instantiatesCanonical
|
0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
|||||
|
instantiatesUri
|
0..* | uri | Instantiates external protocol or definition |
|||||
|
basedOn
|
0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (QI-Core)(USCDI) A request for this procedure |
|||||
|
partOf
|
0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event |
|||||
|
status
|
C | 1..1 | code |
(NHSN-MS) (QI-Core)(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknownBinding: EventStatus (required) |
||||
|
statusReason
|
0..1 | CodeableConcept | (QI-Core) Reason for the current status Binding: QICore Negation Reason Codes (extensible) |
|||||
|
category
|
0..1 | CodeableConcept | 'Surgical Procedure' | 'Diagnostic procedure' Binding: Procedure Category ValueSet (required) |
|||||
|
code
|
C | 1..1 | CodeableConcept |
(NHSN-MS) (QI-Core)(USCDI) Identification of the procedureBinding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure Constraints: not-done-extension-present |
||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
Slices for extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
extension:notDoneValueSet
|
0..1 | canonical(ValueSet) | (QI-Core) What was not performed URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet |
|||||
|
coding
|
0..* | Coding | Code defined by a terminology system |
|||||
|
text
|
0..1 | string | Plain text representation of the concept | |||||
|
subject
|
1..1 | Reference(Cross-Measure Patient Profile) {b} |
(NHSN-MS) (QI-Core)(USCDI) Who the procedure was performed on |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
encounter
|
0..1 | Reference(Encounter) {b} |
(NHSN-MS) (QI-Core)(USCDI) Encounter during which the procedure was performed |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
performed[x]
|
C | 0..1 |
(NHSN-MS) (QI-Core)(USCDI) When the procedure was performed |
|||||
|
performedDateTime
|
dateTime | |||||||
|
performedPeriod
|
Period | |||||||
|
recorder
|
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |||||
|
asserter
|
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |||||
|
performer
|
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
|
0..* | Extension | Extensions that cannot be ignored even if unrecognized |
|||||
|
function
|
0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. |
|||||
|
actor
|
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
|
0..1 | Reference(Location) {b} |
(NHSN-MS) (QI-Core)(USCDI) Where the procedure was performed |
|||||
|
id
|
0..1 | string | Unique id for inter-element referencing | |||||
|
extension
|
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
|||||
|
reference
|
C | 1..1 | string |
(NHSN-MS) Literal reference, Relative, internal or absolute URL |
||||
|
type
|
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). |
|||||
|
identifier
|
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
|
display
|
0..1 | string | Text alternative for the resource | |||||
|
reasonCode
|
0..* | CodeableConcept | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service Binding: ProcedureReasonCodes (preferred) |
|||||
|
reasonReference
|
0..* | Reference(QICore Condition Encounter Diagnosis | QICore Condition Problems Health Concerns | QICore DiagnosticReport Profile for Report and Note Exchange | US Core DocumentReference Profile(6.1.0)) | (QI-Core)(USCDI) Coded reason procedure performed or Explanation/Justification for procedure or service |
|||||
|
bodySite
|
0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
|||||
|
outcome
|
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
|
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
| ||||||||
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| not-done-extension-present | error | Procedure.code | qicore-notDoneValueSet extension does not exist |
extension.where(url='http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet').exists().not()
|
| us-core-7 | error | Procedure | Performed SHALL be present if the status is 'completed' or 'in-progress' |
(status='completed' or status='in-progress') implies performed.exists()
|
This structure is derived from USCoreProcedureProfile
Summary
Mandatory: 2 elements(2 nested mandatory elements)
Must-Support: 6 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
