CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1
CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Local Development build (v1.0.0) 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-monthly-procedure | Version: 1.0.0 | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: AcuteCareHospitalMonthlyReportingProcedure | ||
This profile contains Required and Must Support data elements for reporting procedure information to the NHSN Acute Care Hospital (ACH) Monthly Digital Quality Measure. This profile is based on the HL7 FHIR® US Core Procedure Profile v3.1.1.
Usages:
You can also check for usages in the FHIR IG Statistics
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 |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
 code |
SΣ | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure |
  subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) Who the procedure was performed on |
  reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 performed[x] |
SΣC | 0..1 | (USCDI) When the procedure was performed | |
| performedDateTime |
dateTime S | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| location |
SΣ | 0..1 | Reference(Location) | Where the procedure happened |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible) |
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| bodySite |
SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusFrom the FHIR Standard | |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code|6.1.0 | |
| Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | |
| Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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 | 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 | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
S | 0..1 | Reference(Encounter) | Encounter created as part of |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| location |
S | 0..1 | Reference(Location) | Where the procedure happened |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| reasonCode |
S | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible) |
| reasonReference |
S | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| bodySite |
S | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | |
| Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard |
| 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 |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 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 |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 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 |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| 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 | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
Σ | 0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (USCDI) A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| performed[x] |
SΣC | 0..1 | (USCDI) When the procedure was performed | |||||
| performedDateTime |
dateTime S | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| recorder |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer |
Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location |
SΣ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible) | ||||
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| bodySite |
SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible) | ||||
| outcome |
Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report |
0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail |
0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note |
0..* | Annotation | Additional information about the procedure | |||||
| focalDevice |
0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
1..1 | Reference(Device) | Device that was changed | |||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| Procedure.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| Procedure.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusFrom the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonFrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryFrom the FHIR Standard | ||||
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code|6.1.0 | ||||
| Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-roleFrom the FHIR Standard | ||||
| Procedure.location.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | ||||
| Procedure.reasonReference.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomeFrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codeFrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupFrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionFrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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(3 nested mandatory elements)
Must-Support: 9 elements
Extensions
This structure refers to these extensions:
Maturity: 1
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 |
Σ | 1..1 | id | Logical id of this artifact |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (USCDI) Who the procedure was performed on |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| performed[x] |
SΣC | 0..1 | (USCDI) When the procedure was performed | |
| performedDateTime |
dateTime S | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| location |
SΣ | 0..1 | Reference(Location) | Where the procedure happened |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible) |
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| bodySite |
SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusFrom the FHIR Standard | |
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code|6.1.0 | |
| Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | |
| Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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 | 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 | |
| subject |
||||
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
S | 0..1 | Reference(Encounter) | Encounter created as part of |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| location |
S | 0..1 | Reference(Location) | Where the procedure happened |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| reasonCode |
S | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible) |
| reasonReference |
S | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| reference |
S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| bodySite |
S | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | |
| Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard |
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 |
Σ | 1..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 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 |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 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 |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| 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 | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
Σ | 0..* | Reference(US Core CarePlan Profile(6.1.0) | US Core ServiceRequest Profile) | (USCDI) A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣC | 1..1 | code | (USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code |
SΣ | 1..1 | CodeableConcept | (USCDI) Identification of the procedure Binding: USCoreProcedureCodes (6.1.0) (extensible): Codes describing the type of Procedure | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | (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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| performed[x] |
SΣC | 0..1 | (USCDI) When the procedure was performed | |||||
| performedDateTime |
dateTime S | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| recorder |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter |
Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer |
Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor |
Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf |
0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location |
SΣ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| reasonCode |
SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible) | ||||
| reasonReference |
SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that 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 |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 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 |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| bodySite |
SΣ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible) | ||||
| outcome |
Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report |
0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail |
0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note |
0..* | Annotation | Additional information about the procedure | |||||
| focalDevice |
0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
1..1 | Reference(Device) | Device that was changed | |||||
| usedReference |
0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Procedure.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels|4.0.1From the FHIR Standard | ||||
| Procedure.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags|4.0.1From the FHIR Standard | ||||
| Procedure.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusFrom the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonFrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryFrom the FHIR Standard | ||||
| Procedure.code | extensible | USCoreProcedureCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code|6.1.0 | ||||
| Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-roleFrom the FHIR Standard | ||||
| Procedure.location.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.reasonCode | extensible | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | ||||
| Procedure.reasonReference.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types|4.0.1From the FHIR Standard | ||||
| Procedure.bodySite | extensible | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomeFrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codeFrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupFrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionFrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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(3 nested mandatory elements)
Must-Support: 9 elements
Extensions
This structure refers to these extensions:
Maturity: 1
Other representations of profile: CSV, Excel, Schematron
