HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Resource Profile: Procedure (MY Core)
| Official URL: http://fhir.hie.moh.gov.my/StructureDefinition/Procedure-my-core | Version: 2.0.0 | |||
| Active as of 2024-03-13 | Computable Name: ProcedureMyCore | |||
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.
Usage:
- Examples for this Resource Profile: Procedure/example-procedure
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure |
0..* | Procedure | An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
   recorded |
0..1 | dateTime | Extension about the date procedure was recorded URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-recorded-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| primaryDiscipline |
0..1 | CodeableConcept | Extension about the discipline performing the procedure URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-primary-discipline-my-core Binding: ValueSetSpecialty (MYCore) (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
 sessionType |
0..1 | CodeableConcept | Extension about the type of procedure session URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-session-type-my-core Binding: ValueSetProcedureSessionType (MY Core) (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| status |
?!Σ | 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. ele-1: All FHIR elements must have a @value or children |
 category |
Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ValueSetProcedureCategory (MY Core) (required) ele-1: All FHIR elements must have a @value or children |
| code |
Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ValueSetProcedureCode (MY Core) (example) ele-1: All FHIR elements must have a @value or children |
 subject |
Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on ele-1: All FHIR elements must have a @value or children |
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of ele-1: All FHIR elements must have a @value or children |
 performed[x] |
Σ | 1..1 | When the procedure was performed ele-1: All FHIR elements must have a @value or children | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
 performedRange |
Range | |||
 Slices for bodySite |
Σ | 0..* | CodeableConcept | Target body sites Slice: Unordered, Open by value:coding.id Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. ele-1: All FHIR elements must have a @value or children |
| bodySite:side |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSide (MY Core) (example) ele-1: All FHIR elements must have a @value or children |
| bodySite:site |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSite (MY Core) (example) ele-1: All FHIR elements must have a @value or children |
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: ValueSetProcedureComplication (MY Core) (example) ele-1: All FHIR elements must have a @value or children | |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.category | required | ValueSetProcedureCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-category-my-corefrom this IG | |
| Procedure.code | example | ValueSetProcedureCodeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-code-my-corefrom this IG | |
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | |
| Procedure.bodySite:side | example | ValueSetSideMyCorehttp://fhir.hie.moh.gov.my/ValueSet/side-my-corefrom this IG | |
| Procedure.bodySite:site | example | ValueSetSiteMyCorehttp://fhir.hie.moh.gov.my/ValueSet/site-my-corefrom this IG | |
| Procedure.complication | example | ValueSetProcedureComplicationMyCore (a valid code from CodeSystemProcedureComplication (MY Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-complication-my-corefrom this IG |
Constraints
| 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() |
This structure is derived from Procedure
Terminology Bindings (Differential)
| Path | Conformance | ValueSet | URI |
| Procedure.category | required | ValueSetProcedureCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-category-my-corefrom this IG | |
| Procedure.code | example | ValueSetProcedureCodeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-code-my-corefrom this IG | |
| Procedure.performer.function | preferred | ValueSetProcedurePerformerRole (a valid code from CodeSystemProcedurePerformerRole (My Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-performer-role-my-corefrom this IG | |
| Procedure.bodySite:side | example | ValueSetSideMyCorehttp://fhir.hie.moh.gov.my/ValueSet/side-my-corefrom this IG | |
| Procedure.bodySite:site | example | ValueSetSiteMyCorehttp://fhir.hie.moh.gov.my/ValueSet/site-my-corefrom this IG | |
| Procedure.complication | example | ValueSetProcedureComplicationMyCore (a valid code from CodeSystemProcedureComplication (MY Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-complication-my-corefrom this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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 | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| recorded |
0..1 | dateTime | Extension about the date procedure was recorded URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-recorded-my-core | |||||
| primaryDiscipline |
0..1 | CodeableConcept | Extension about the discipline performing the procedure URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-primary-discipline-my-core Binding: ValueSetSpecialty (MYCore) (required) | |||||
| sessionType |
0..1 | CodeableConcept | Extension about the type of procedure session URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-session-type-my-core Binding: ValueSetProcedureSessionType (MY Core) (required) | |||||
| 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(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!Σ | 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 |
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 | 1..1 | CodeableConcept | Classification of the procedure Binding: ValueSetProcedureCategory (MY Core) (required) | ||||
| code |
Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ValueSetProcedureCode (MY Core) (example) | ||||
| subject |
Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on | ||||
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] |
Σ | 1..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime | |||||||
| 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: ValueSetProcedurePerformerRole (MY Core) (preferred) | ||||
| 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 |
Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| Slices for bodySite |
Σ | 0..* | CodeableConcept | Target body sites Slice: Unordered, Open by value:coding.id Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
 bodySite:side |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSide (MY Core) (example) | ||||
  id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
 coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
 id |
1..1 | string | Unique id for inter-element referencing Fixed Value: side | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 0..1 | uri | Identity of the terminology system | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
 text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
 bodySite:site |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSite (MY Core) (example) | ||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id |
1..1 | string | Unique id for inter-element referencing Fixed Value: site | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 0..1 | uri | Identity of the terminology system | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| 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: ValueSetProcedureComplication (MY Core) (example) | |||||
| 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 | ||||||||
Terminology Bindings
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | required | ValueSetProcedureCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-category-my-corefrom this IG | ||||
| Procedure.code | example | ValueSetProcedureCodeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-code-my-corefrom this IG | ||||
| Procedure.performer.function | preferred | ValueSetProcedurePerformerRole (a valid code from CodeSystemProcedurePerformerRole (My Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-performer-role-my-corefrom this IG | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.bodySite:side | example | ValueSetSideMyCorehttp://fhir.hie.moh.gov.my/ValueSet/side-my-corefrom this IG | ||||
| Procedure.bodySite:site | example | ValueSetSiteMyCorehttp://fhir.hie.moh.gov.my/ValueSet/site-my-corefrom this IG | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | ValueSetProcedureComplicationMyCore (a valid code from CodeSystemProcedureComplication (MY Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-complication-my-corefrom this IG | ||||
| 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 |
Constraints
| 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() |
This structure is derived from Procedure
Summary
Mandatory: 4 elements(2 nested mandatory elements)
Fixed: 2 elements
Extensions
This structure refers to these extensions:
- http://fhir.hie.moh.gov.my/StructureDefinition/procedure-recorded-my-core
- http://fhir.hie.moh.gov.my/StructureDefinition/procedure-primary-discipline-my-core
- http://fhir.hie.moh.gov.my/StructureDefinition/procedure-session-type-my-core
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of Procedure.bodySite
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| recorded |
0..1 | dateTime | Extension about the date procedure was recorded URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-recorded-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| primaryDiscipline |
0..1 | CodeableConcept | Extension about the discipline performing the procedure URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-primary-discipline-my-core Binding: ValueSetSpecialty (MYCore) (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| sessionType |
0..1 | CodeableConcept | Extension about the type of procedure session URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-session-type-my-core Binding: ValueSetProcedureSessionType (MY Core) (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| status |
?!Σ | 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. ele-1: All FHIR elements must have a @value or children |
| category |
Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ValueSetProcedureCategory (MY Core) (required) ele-1: All FHIR elements must have a @value or children |
| code |
Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ValueSetProcedureCode (MY Core) (example) ele-1: All FHIR elements must have a @value or children |
| subject |
Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on ele-1: All FHIR elements must have a @value or children |
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of ele-1: All FHIR elements must have a @value or children |
| performed[x] |
Σ | 1..1 | When the procedure was performed ele-1: All FHIR elements must have a @value or children | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| Slices for bodySite |
Σ | 0..* | CodeableConcept | Target body sites Slice: Unordered, Open by value:coding.id Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. ele-1: All FHIR elements must have a @value or children |
| bodySite:side |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSide (MY Core) (example) ele-1: All FHIR elements must have a @value or children |
| bodySite:site |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSite (MY Core) (example) ele-1: All FHIR elements must have a @value or children |
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: ValueSetProcedureComplication (MY Core) (example) ele-1: All FHIR elements must have a @value or children | |
| Documentation for this format | ||||
Terminology Bindings
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.category | required | ValueSetProcedureCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-category-my-corefrom this IG | |
| Procedure.code | example | ValueSetProcedureCodeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-code-my-corefrom this IG | |
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | |
| Procedure.bodySite:side | example | ValueSetSideMyCorehttp://fhir.hie.moh.gov.my/ValueSet/side-my-corefrom this IG | |
| Procedure.bodySite:site | example | ValueSetSiteMyCorehttp://fhir.hie.moh.gov.my/ValueSet/site-my-corefrom this IG | |
| Procedure.complication | example | ValueSetProcedureComplicationMyCore (a valid code from CodeSystemProcedureComplication (MY Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-complication-my-corefrom this IG |
Constraints
| 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() |
Differential View
This structure is derived from Procedure
Terminology Bindings (Differential)
| Path | Conformance | ValueSet | URI |
| Procedure.category | required | ValueSetProcedureCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-category-my-corefrom this IG | |
| Procedure.code | example | ValueSetProcedureCodeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-code-my-corefrom this IG | |
| Procedure.performer.function | preferred | ValueSetProcedurePerformerRole (a valid code from CodeSystemProcedurePerformerRole (My Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-performer-role-my-corefrom this IG | |
| Procedure.bodySite:side | example | ValueSetSideMyCorehttp://fhir.hie.moh.gov.my/ValueSet/side-my-corefrom this IG | |
| Procedure.bodySite:site | example | ValueSetSiteMyCorehttp://fhir.hie.moh.gov.my/ValueSet/site-my-corefrom this IG | |
| Procedure.complication | example | ValueSetProcedureComplicationMyCore (a valid code from CodeSystemProcedureComplication (MY Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-complication-my-corefrom this IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| 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 | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| recorded |
0..1 | dateTime | Extension about the date procedure was recorded URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-recorded-my-core | |||||
| primaryDiscipline |
0..1 | CodeableConcept | Extension about the discipline performing the procedure URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-primary-discipline-my-core Binding: ValueSetSpecialty (MYCore) (required) | |||||
| sessionType |
0..1 | CodeableConcept | Extension about the type of procedure session URL: http://fhir.hie.moh.gov.my/StructureDefinition/procedure-session-type-my-core Binding: ValueSetProcedureSessionType (MY Core) (required) | |||||
| 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(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!Σ | 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 |
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 | 1..1 | CodeableConcept | Classification of the procedure Binding: ValueSetProcedureCategory (MY Core) (required) | ||||
| code |
Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: ValueSetProcedureCode (MY Core) (example) | ||||
| subject |
Σ | 1..1 | Reference(Patient | Group) | Who the procedure was performed on | ||||
| encounter |
Σ | 1..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] |
Σ | 1..1 | When the procedure was performed | |||||
| performedDateTime |
dateTime | |||||||
| 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: ValueSetProcedurePerformerRole (MY Core) (preferred) | ||||
| 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 |
Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| Slices for bodySite |
Σ | 0..* | CodeableConcept | Target body sites Slice: Unordered, Open by value:coding.id Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| bodySite:side |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSide (MY Core) (example) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id |
1..1 | string | Unique id for inter-element referencing Fixed Value: side | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 0..1 | uri | Identity of the terminology system | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| bodySite:site |
Σ | 0..* | CodeableConcept | Target body sites Binding: ValueSetSite (MY Core) (example) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id |
1..1 | string | Unique id for inter-element referencing Fixed Value: site | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
Σ | 0..1 | uri | Identity of the terminology system | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| 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: ValueSetProcedureComplication (MY Core) (example) | |||||
| 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 | ||||||||
Terminology Bindings
| Path | Conformance | ValueSet | URI | |||
| Procedure.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | required | ValueSetProcedureCategoryMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-category-my-corefrom this IG | ||||
| Procedure.code | example | ValueSetProcedureCodeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/procedure-code-my-corefrom this IG | ||||
| Procedure.performer.function | preferred | ValueSetProcedurePerformerRole (a valid code from CodeSystemProcedurePerformerRole (My Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-performer-role-my-corefrom this IG | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.bodySite:side | example | ValueSetSideMyCorehttp://fhir.hie.moh.gov.my/ValueSet/side-my-corefrom this IG | ||||
| Procedure.bodySite:site | example | ValueSetSiteMyCorehttp://fhir.hie.moh.gov.my/ValueSet/site-my-corefrom this IG | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | ValueSetProcedureComplicationMyCore (a valid code from CodeSystemProcedureComplication (MY Core))http://fhir.hie.moh.gov.my/ValueSet/procedure-complication-my-corefrom this IG | ||||
| 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 |
Constraints
| 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() |
This structure is derived from Procedure
Summary
Mandatory: 4 elements(2 nested mandatory elements)
Fixed: 2 elements
Extensions
This structure refers to these extensions:
- http://fhir.hie.moh.gov.my/StructureDefinition/procedure-recorded-my-core
- http://fhir.hie.moh.gov.my/StructureDefinition/procedure-primary-discipline-my-core
- http://fhir.hie.moh.gov.my/StructureDefinition/procedure-session-type-my-core
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of Procedure.bodySite
Other representations of profile: CSV, Excel, Schematron
Notes:
Mandatory Data Elements
This structure defines these elements as mandatory data fields:
| Element | Description |
|---|---|
Procedure.status
|
Status of the Procedure in the workflow, e.g. in-progress, completed. |
Procedure.category
|
General category of the Procedure, e.g. surgical, dental, diagnostic. |
Procedure.code
|
Coding for the specific type of Procedure, e.g. suturing, debridement, Ryle's tube insertion. |
Procedure.subject
|
References the Patient or Group undergoing the procedure. |
Procedure.encounter
|
References the Encounter when the Procedure was performed. |
Procedure.performed.performedPeriod.start
|
Date and time the procedure was started. |
Slices
This structure slices the following elements:
| Element | Discriminator Path (Type) | Value |
|---|---|---|
Procedure.bodySite
|
:side.coding.id(Value)
|
side |
:site.coding.id(Value)
|
site |