Procedure | Medplum

Procedure

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

Elements

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