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Patient Care Work GroupMaturity Level: 3 Trial Use Compartments: Encounter, Patient, Practitioner, RelatedPerson

Подробное описание элементов ресурса Procedure.

Procedure
Element IdProcedure
Definition

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

Control0..*
TypeDomainResource
Procedure.identifier
Element IdProcedure.identifier
Definition

Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and propagates from server to server.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Summarytrue
Comments

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.

Procedure.instantiatesCanonical
Element IdProcedure.instantiatesCanonical
Definition

The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this Procedure.

Control0..*
Typecanonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)
Summarytrue
Procedure.instantiatesUri
Element IdProcedure.instantiatesUri
Definition

The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this Procedure.

Control0..*
Typeuri
Summarytrue
Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Procedure.basedOn
Element IdProcedure.basedOn
Definition

Ссылка на ресурс, содержащий сведения о запросе на данную процедуру.

Control0..*
TypeReference(CarePlan | ServiceRequest)
Alternate Namesfulfills
Summarytrue
Procedure.partOf
Element IdProcedure.partOf
Definition

A larger event of which this particular procedure is a component or step.

Control0..*
TypeReference(Procedure | Observation | MedicationAdministration)
Alternate Namescontainer
Summarytrue
Comments

The MedicationAdministration has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Procedure.status
Element IdProcedure.status
Definition

Код состояния записи о процедуре. Как правило, это будет состояние in-progress или completed.

Control1..1
Terminology BindingEventStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

The unknown code is not to be used to convey other statuses. The unknown code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Procedure.statusReason
Element IdProcedure.statusReason
Definition

Captures the reason for the current state of the procedure.

Control0..1
Terminology BindingProcedure Not Performed Reason (SNOMED-CT) (Example)
TypeCodeableConcept
Alternate NamesSuspended Reason; Cancelled Reason
Summarytrue
Comments

This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

Procedure.category
Element IdProcedure.category
Definition

Код, классифицирующий процедуру в целях поиска и отображения (например "хирургическое вмешательство").

Control0..1
Terminology BindingProcedure Category Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Procedure.code
Element IdProcedure.code
Definition

Конкретная процедура, которая была выполнена. Используйте текст, если точный характер процедуры не может быть закодирован (например "лапароскопическая аппендэктомия").

Control0..1
Terminology BindingProcedure Codes (SNOMED CT) (Example)
TypeCodeableConcept
Requirements

0..1 to account for primarily narrative only resources.

Alternate Namestype
Summarytrue
Procedure.subject
Element IdProcedure.subject
Definition

Человек, животное или группа, над которой выполнялась процедура.

Control1..1
TypeReference(Patient | Group)
Alternate Namespatient
Summarytrue
Procedure.encounter
Element IdProcedure.encounter
Definition

The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Control0..1
TypeReference(Encounter)
Summarytrue
Comments

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Procedure.performed[x]
Element IdProcedure.performed[x]
Definition

Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Control0..1
TypedateTime|Period|string|Age|Range
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Comments

Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Procedure.recorder
Element IdProcedure.recorder
Definition

Individual who recorded the record and takes responsibility for its content.

Control0..1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole)
Summarytrue
Procedure.asserter
Element IdProcedure.asserter
Definition

Individual who is making the procedure statement.

Control0..1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole)
Summarytrue
Procedure.performer
Element IdProcedure.performer
Definition

Описание реальных людей, а не оборудования.

Control0..*
Summarytrue
Procedure.performer.function
Element IdProcedure.performer.function
Definition

Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaethetist, endoscopist.

Control0..1
Terminology BindingProcedure Performer Role Codes (Example)
TypeCodeableConcept
Requirements

Allows disambiguation of the types of involvement of different performers.

Summarytrue
Procedure.performer.actor
Element IdProcedure.performer.actor
Definition

Медицинский специалист, который участвовал в процедуре.

Control1..1
TypeReference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)
Requirements

A reference to Device supports use cases, such as pacemakers.

Summarytrue
Procedure.performer.onBehalfOf
Element IdProcedure.performer.onBehalfOf
Definition

The organization the device or practitioner was acting on behalf of.

Control0..1
TypeReference(Organization)
Requirements

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Procedure.location
Element IdProcedure.location
Definition

Место, где была проведена процедура. Например роды приняты на дому, трахеостомия в ресторане.

Control0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Summarytrue
Procedure.reasonCode
Element IdProcedure.reasonCode
Definition

The coded reason why the procedure was performed. This may be coded entity of some type, or may simply be present as text.

Control0..*
Terminology BindingProcedure Reason Codes (Example)
TypeCodeableConcept
Summarytrue
Comments

Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Procedure.reasonReference
Element IdProcedure.reasonReference
Definition

The justification of why the procedure was performed.

Control0..*
TypeReference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
Summarytrue
Comments

It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as epidural). Other examples include endoscopy for dilatation and biopsy, combination diagnosis and therapeutic. Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Procedure.bodySite
Element IdProcedure.bodySite
Definition

Подробная и структурированная информация об анатомическом расположении. Можно указывать несколько местоположений - например многократная пункционная биопсия раны.

Control0..*
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summarytrue
Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Procedure.outcome
Element IdProcedure.outcome
Definition

Результат процедуры - решила ли она те вопросы, которые были основанием для ее выполнения?

Control0..1
Terminology BindingProcedure Outcome Codes (SNOMED CT) (Example)
TypeCodeableConcept
Summarytrue
Comments

Если результат содержит только текстовую часть, его можно записать в элемент CodeableConcept.text.

Procedure.report
Element IdProcedure.report
Definition

Это может быть гистологический результат, патологический отчёт, хирургический отчёт и т. п.

Control0..*
TypeReference(DiagnosticReport | DocumentReference | Composition)
Comments

Здесь может быть несколько отчетов - например если во время процедуры было сделано несколько биопсий, в результате чего получилось несколько анатомических патологических отчётов.

Procedure.complication
Element IdProcedure.complication
Definition

Любые осложнения, произошедшие во время выполнения процедуры или в последующий послеоперационный период. Как правило, они отслеживаются отдельно от записей, которые обычно описывают саму процедуру, а нее возникшие после неё проблемы.

Control0..*
Terminology BindingCondition/Problem/Diagnosis Codes (Example)
TypeCodeableConcept
Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Procedure.complicationDetail
Element IdProcedure.complicationDetail
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Control0..*
TypeReference(Condition)
Requirements

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Procedure.followUp
Element IdProcedure.followUp
Definition

Если процедура требует определенного последующего наблюдения - например удаления швов. Может быть как простым примечанием, так и более сложным, во втором случае можно использовать ресурс CarePlan.

Control0..*
Terminology BindingProcedure Follow up Codes (SNOMED CT) (Example)
TypeCodeableConcept
Procedure.note
Element IdProcedure.note
Definition

Any other notes and comments about the procedure.

Control0..*
TypeAnnotation
Procedure.focalDevice
Element IdProcedure.focalDevice
Definition

Медицинское изделие, которое было имплантировано, удалено или над ним была проведена другая манипуляция (калибровка, смена батарейки, подгонка протеза, вакуумное закрытие раны и др.) в рамках данной процедуры.

Control0..*
Procedure.focalDevice.action
Element IdProcedure.focalDevice.action
Definition

Тип изменения, которое произошло с изделием во время процедуры.

Control0..1
Terminology BindingProcedure Device Action Codes (Preferred)
TypeCodeableConcept
Procedure.focalDevice.manipulated
Element IdProcedure.focalDevice.manipulated
Definition

Медицинское изделие, которое отрегулировали (изменили) во время процедуры.

Control1..1
TypeReference(Device)
Procedure.usedReference
Element IdProcedure.usedReference
Definition

Указание лекарственных средств, медицинских изделий или других веществ, использованных в рамках процедуры.

Control0..*
TypeReference(Device | Medication | Substance)
Requirements

Используется для отслеживания заражений и т. п.

Comments

Для имплантированных или извлеченных медицинских изделий используйте Procedure.device.

Procedure.usedCode
Element IdProcedure.usedCode
Definition

Identifies coded items that were used as part of the procedure.

Control0..*
Terminology BindingFHIR Device Types (Example)
TypeCodeableConcept
Comments

Для имплантированных или извлеченных медицинских изделий используйте Procedure.device.