Australian Digital Health Agency FHIR Implementation Guide 1.1.0

This page is part of the Australian Digital Health Agency FHIR Implementation Guide 1.1.0. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available previous versions.

StructureDefinition: ADHA Core Procedure [Active]

The purpose of this profile is to provide a core representation of a procedure for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile identifies the additional constraints, extensions, and value sets that build on and extend Procedure that are supported.

This profile is designed to set a core Procedure standard for:

  • Query for procedures performed for a patient
  • Record or update a procedure performed for a patient

Profile specific guidance

  • Procedure.category provides an efficient way of supporting system interactions, e.g. restricting searches. Implementers need to understand that data categorisation is somewhat subjective. The categorisation applied by the source may not align with a receiver’s expectations.
  • In an exchange with the My Health Record system Procedure.status is “completed”.
  • The Procedure resource can represent a reason as a code with Procedure.reasonCode, or a reference with Procedure.reasonReference to a Condition or other resource.
    • Although both are marked as must support, sending systems are not required to support both a code and a reference, but they SHALL support at least one of these elements.
    • A receiving or persisting system SHALL support both elements.
  • A procedure including an implantable device should use Procedure.focalDevice with a reference to a Device resource.

Boundaries and relationships

This profile is referenced by ADHA Core Encounter, ADHA Core Flag, and ADHA Core Procedure.

Formal Views of Profile Content

The official URL for this profile is: 

http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-procedure-core-1

The purpose of this profile is to provide a core representation of a procedure for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia.

This profile builds on AUBaseProcedure.

This profile was published on 2023-08-07 09:41:43+1000 as a active by Australian Digital Health Agency.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*AUBaseProcedureA procedure in an Australian healthcare context
inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
... status S1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... statusReason S0..1CodeableConceptReason for current status
... category S1..1CodeableConceptClassification of the procedure
... code S1..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
... subject SC1..1Reference(ADHA Core Patient)Who the procedure was performed on
inv-dh-pro-02: At least reference or a valid identifier shall be present
... encounter S0..1Reference(ADHA Core Encounter)Encounter created as part of
... performed[x] S1..1dateTime, Period, string, Age, RangeWhen the procedure was performed
... recorder SC1..1Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)Who recorded the procedure
inv-dh-pro-03: At least reference or display or a valid identifier shall be present
... asserter SC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this procedure
... reasonCode S0..*CodeableConceptCoded reason procedure performed
... reasonReference[x] S0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)The justification that the procedure was performed
... bodySite SC0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... note S0..*AnnotationAdditional information about the procedure

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*AUBaseProcedureA procedure in an Australian healthcare context
inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... targetBodyStructure 0..*Reference(BodyStructure)The target point for this procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason SΣ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ1..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code SΣ1..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
... subject SΣC1..1Reference(ADHA Core Patient)Who the procedure was performed on
inv-dh-pro-02: At least reference or a valid identifier shall be present
... encounter SΣ0..1Reference(ADHA Core Encounter)Encounter created as part of
... performed[x] SΣ1..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder SΣC1..1Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)Who recorded the procedure
inv-dh-pro-03: At least reference or display or a valid identifier shall be present
... asserter SΣC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode SΣ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference SΣ0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)The justification that the procedure was performed
... bodySite SΣC0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note S0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*AUBaseProcedureA procedure in an Australian healthcare context
inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
... status S1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... statusReason S0..1CodeableConceptReason for current status
... category S1..1CodeableConceptClassification of the procedure
... code S1..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
... subject SC1..1Reference(ADHA Core Patient)Who the procedure was performed on
inv-dh-pro-02: At least reference or a valid identifier shall be present
... encounter S0..1Reference(ADHA Core Encounter)Encounter created as part of
... performed[x] S1..1dateTime, Period, string, Age, RangeWhen the procedure was performed
... recorder SC1..1Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)Who recorded the procedure
inv-dh-pro-03: At least reference or display or a valid identifier shall be present
... asserter SC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this procedure
... reasonCode S0..*CodeableConceptCoded reason procedure performed
... reasonReference[x] S0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)The justification that the procedure was performed
... bodySite SC0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... note S0..*AnnotationAdditional information about the procedure

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure C0..*AUBaseProcedureA procedure in an Australian healthcare context
inv-dh-pro-01: If present, an asserter shall at least have a reference, an identifier or a display
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... targetBodyStructure 0..*Reference(BodyStructure)The target point for this procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason SΣ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ1..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code SΣ1..1CodeableConceptIdentification of the procedure
Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
... subject SΣC1..1Reference(ADHA Core Patient)Who the procedure was performed on
inv-dh-pro-02: At least reference or a valid identifier shall be present
... encounter SΣ0..1Reference(ADHA Core Encounter)Encounter created as part of
... performed[x] SΣ1..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder SΣC1..1Reference(ADHA Authoring PractitionerRole | ADHA Core Patient | ADHA Authoring RelatedPerson)Who recorded the procedure
inv-dh-pro-03: At least reference or display or a valid identifier shall be present
... asserter SΣC0..1Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode SΣ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference SΣ0..*Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference)The justification that the procedure was performed
... bodySite SΣC0..*CodeableConceptTarget body sites
Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible)
inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note S0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codeextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteextensiblehttps://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Search Parameters

None defined.