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
Resource Profile: ACH Daily Event Procedure
| 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 dQM. 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:
- Examples for this Profile: Procedure/procedure-example-ach-daily-negativepcr-intubation
You can also check for usages in the FHIR IG Statistics
Changes since version 1.0.0:
Formal Views of Profile Content
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 |
|
   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
| ||||
Terminology Bindings
| 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. |
Constraints
| 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 |
|
|
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
| ||||
Terminology Bindings (Differential)
| 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. |
Constraints
| 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 |
|||||
|
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
| ||||||||
Terminology Bindings
Constraints
| 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:
- Cross-Measure Patient Profile (http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/cross-measure-patient)
- QICore Condition Encounter Diagnosis (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis)
- QICore Condition Problems Health Concerns (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns)
- QICore DiagnosticReport Profile for Report and Note Exchange (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note)
- US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference|6.1.0)
Extensions
This structure refers to these extensions:
- http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
- http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
- http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
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 |
|
|
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
| ||||
Terminology Bindings
| 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. |
Constraints
| 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 |
|
|
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
| ||||
Terminology Bindings (Differential)
| 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. |
Constraints
| 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 |
|||||
|
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
| ||||||||
Terminology Bindings
Constraints
| 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:
- Cross-Measure Patient Profile (http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/cross-measure-patient)
- QICore Condition Encounter Diagnosis (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis)
- QICore Condition Problems Health Concerns (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns)
- QICore DiagnosticReport Profile for Report and Note Exchange (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note)
- US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference|6.1.0)
Extensions
This structure refers to these extensions:
- http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
- http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-recorded
- http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-notDoneValueSet
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
