EOLDocument

COFE-IssueOfAnticipatoryMeds-Procedure-1

COFE-IssueOfAnticipatoryMeds-Procedure-1

Procedure
Definition

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

Control 0..*
Type Procedure
Comments
Procedure.extension(Author)
Definition

Optional Extensions Element - found in all resources.

Control 0..1
Type Extension
Comments
Procedure.extension(AM Box Location)
Definition

Optional Extensions Element - found in all resources.

Control 1..1
Type Extension
Comments
Procedure.extension(Medication Choice)
Definition

Optional Extensions Element - found in all resources.

Control 0..1
Type Extension
Comments
Procedure.identifier
Definition

This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

Control 1..1
Type Identifier
Requirements

Need to allow connection to a wider workflow.

Comments
Procedure.identifier.value
Definition

The portion of the identifier typically displayed to the user and which is unique within the context of the system.

Control 1..1
Type String
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.

Example 046fcf2d-80b0-4912-a50c-dd1293dbbed8
Procedure.subject
Definition

The person, animal or group on which the procedure was performed.

Control 1..1
Comments
Procedure.status
Definition

A code specifying the state of the procedure. Generally this will be in-progress or completed state.

Control 1..1
Binding

A code specifying the state of the procedure.

The codes SHALL be taken from http://hl7.org/fhir/ValueSet/procedure-status

Type Code
Is Modifier True
Comments
Fixed Value completed
Procedure.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Control 1..1
Binding

A code to identify a specific procedure .

The codes SHALL be taken from http://fhir.nhs.net/ValueSet/issue-of-anticipatory-meds-1

Type CodeableConcept
Comments
Procedure.code.coding
Definition

A reference to a code defined by a terminology system.

Control 1..1
Type Coding
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.

Procedure.code.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

Control 1..1
Type Uri
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

Fixed Value http://fhir.nhs.net/ValueSet/issue-of-anticipatory-meds-1
Procedure.code.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Control 1..1
Type Code
Requirements

Need to refer to a particular code in the system.

Comments
Example 376201000000102
Procedure.code.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

Control 1..1
Type String
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments
Example Issue of palliative care anticipatory medication box (procedure)
Procedure.code.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control 0..1
Type String
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

Procedure.performer
Definition

Limited to 'real' people rather than equipment.

Control 0..1
Type BackboneElement
Comments
Procedure.performer.modifierExtension
Definition

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 that contains it. Usually modifier elements provide negation or qualification. In order 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 is allowed to 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.

Control 0..*
Type Extension
Is Modifier True
Aliases extensions, user content, modifiers
Comments

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.

Procedure.performer.actor
Definition

The practitioner who was involved in the procedure.

Control 0..1
Comments
Procedure.performed[x]
Definition

The date(time)/period over which 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.

Control 1..1
Type DateTime
Comments
Procedure.encounter
Definition

The encounter during which the procedure was performed.

Control 0..1
Type Encounter
Comments
Procedure.encounter.reference
Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Control 1..1 ?
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Procedure.encounter.display
Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Control 0..1
Type String
Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.