ADHA Core Procedure - My Health Record FHIR IG v1.2.0

My Health Record FHIR IG
1.2.0 - active Australia flag

My Health Record FHIR IG - Local Development build (v1.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: ADHA Core Procedure

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-procedure-core-1				Version: 1.2.0
Active as of 2024-09-19				Computable Name: ADHAProcedureCore
Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

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.

Usage:

Refer to this Resource Profile: ADHA Core Encounter, ADHA Core Flag and ADHA Core Procedure
Examples for this Resource Profile: Procedure/wound-dressing-es-01

Formal Views of Profile Content

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

This structure is derived from AUBaseProcedure

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A 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	S	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown
statusReason	S	0..1	CodeableConcept	Reason for current status
category	S	1..1	CodeableConcept	Classification of the procedure
code	S	1..1	CodeableConcept	Identification of the procedure Binding: Procedure (extensible)
subject	SC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	S	0..1	Reference(ADHA Core Encounter)	Encounter created as part of
performed[x]	S	1..1	dateTime, Period, string, Age, Range	When the procedure was performed
recorder	SC	1..1	Reference(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	SC	0..1	Reference(ADHA Core PractitionerRole \| ADHA Core Patient \| ADHA Core RelatedPerson)	Person who asserts this procedure
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed
reasonReference	S	0..*	Reference(ADHA Core Condition \| ADHA Core Observation \| ADHA Core Procedure \| ADHA Core DocumentReference)	The justification that the procedure was performed
bodySite	SC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	Procedure `https://healthterminologies.gov.au/fhir/ValueSet/procedure-1` from https://tx.ontoserver.csiro.au/fhir
Procedure.bodySite	extensible	BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	AUBaseProcedure	A 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
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
targetBodyStructure		0..*	Reference(BodyStructure)	The target point for this procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-targetBodyStructure
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	SΣ	1..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	Identification of the procedure Binding: Procedure (extensible)
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who the procedure was performed on inv-dh-pro-02: At least reference or a valid identifier shall be present
encounter	SΣ	0..1	Reference(ADHA Core Encounter)	Encounter created as part of
performed[x]	SΣ	1..1		When the procedure was performed
performedDateTime			dateTime
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
recorder	SΣC	1..1	Reference(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	SΣC	0..1	Reference(ADHA Core PractitionerRole \| ADHA Core Patient \| ADHA Core RelatedPerson)	Person who asserts this procedure
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	SΣ	0..*	Reference(ADHA Core Condition \| ADHA Core Observation \| ADHA Core Procedure \| ADHA Core DocumentReference)	The justification that the procedure was performed
bodySite	SΣC	0..*	CodeableConcept	Target body sites Binding: Body Site (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
note	S	0..*	Annotation	Additional information about the procedure
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus `http://hl7.org/fhir/ValueSet/event-status\|4.0.1` from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) `http://hl7.org/fhir/ValueSet/procedure-not-performed-reason` from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-category` from the FHIR Standard
Procedure.code	extensible	Procedure `https://healthterminologies.gov.au/fhir/ValueSet/procedure-1` from https://tx.ontoserver.csiro.au/fhir
Procedure.reasonCode	example	ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` from the FHIR Standard
Procedure.bodySite	extensible	BodySite `https://healthterminologies.gov.au/fhir/ValueSet/body-site-1` from https://tx.ontoserver.csiro.au/fhir

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-pro-01	error	Procedure	If present, an asserter shall at least have a reference, an identifier or a display : asserter.exists() implies asserter.all($this.reference.exists() or $this.identifier.exists() or $this.display.exists())
inv-dh-pro-02	error	Procedure.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-03	error	Procedure.recorder	At least reference or display or a valid identifier shall be present : reference.exists() or display.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-pro-04	error	Procedure.bodySite	If a coded body site is provided, at least one code shall be from SNOMED CT : coding.exists() implies coding.where(system='http://snomed.info/sct').exists()