Procedure Base Inera - Definitions - Inera Core Implementation Guide v0.2.0

Is Modifier false

Summary true

4. Procedure.meta

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Short Metadata about the resource

Control 0..1

Meta

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

6. Procedure.implicitRules

Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Short A set of rules under which this content was created

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control 0..1

uri

Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

8. Procedure.language

Definition

The base language in which the resource is written.

Short Language of the resource content

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control 0..1

The codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages|4.0.1)

A human language.

Additional Bindings

Purpose

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

10. Procedure.text

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Short Text summary of the resource, for human interpretation

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control 0..1

Narrative

Is Modifier false

Summary false

Alternate Names narrative, html, xhtml, display

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

12. Procedure.contained

Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Short Contained, inline Resources

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control 0..*

Resource

Is Modifier false

Summary false

Alternate Names inline resources, anonymous resources, contained resources

14. Procedure.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())

Slicing

This element introduces a set of slices on Procedure.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

16. Procedure.extension:method

Slice Name method

Definition

Metod eller teknik som användes vid aktiviteten.

TKB-källa: activityGroup.activity.method

Short Metod/teknik

Comments

Improve definition. Add mappings.

Control 0..1

Type Extension(Procedure Method) (Extension Type: CodeableConcept)

Is Modifier false

Must Support true

Summary false

18. Procedure.modifierExtension

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it 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 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.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensions that cannot be ignored

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.

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them

Summary false

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Names extensions, user content

20. Procedure.identifier

Definition

Unikt ID för aktiviteten inom källsystemet.

identifier.system: Källsystemets HSA-ID (OID 1.2.752.129.2.1.4.1)
identifier.value: Lokalt aktivitets-ID

TKB-källa: activityGroup.activity.id (id.root = HSA-ID, id.extension = local ID)

Short Aktivitets-ID från källsystem

Comments

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.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..*

Identifier

Is Modifier false

Must Support true

Summary true

Requirements

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

22. Procedure.instantiatesCanonical

Definition

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.

Short Instantiates FHIR protocol or definition

Control 0..*

Type canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

24. Procedure.instantiatesUri

Definition

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.

Short Instantiates external protocol or definition

Comments

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Control 0..*

uri

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

26. Procedure.basedOn

Definition

Referens till vårdprocess (EpisodeOfCare), ordination eller planering som aktiviteten baseras på.

TKB-källa: activityGroup.careProcessId → EpisodeOfCare (vårdprocess-UUID)

Short Vårdprocess, ordination, planering

Control 0..*

Type Reference(CarePlan, ServiceRequest)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Alternate Names fulfills

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

28. Procedure.partOf

Definition

Referens till större aktivitet som denna aktivitet ingår i (endast Procedure, Observation, MedicationAdministration).

TKB-källa: activityGroup.activity.relation → Procedure (när relationstyp indikerar hierarki)

Short Del av större aktivitet

Comments

The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Control 0..*

Type Reference(Procedure, Observation, MedicationAdministration)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Alternate Names container

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

30. Procedure.status

Definition

Status för aktiviteten: preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown.

TKB-källa: activityGroup.activity.status (kräver mappning från TKB-kodsystem)

Short Status

Comments

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.

Control 1..1

The codes SHALL be taken from EventStatus
(required to http://hl7.org/fhir/ValueSet/event-status|4.0.1)

A code specifying the state of the procedure.

code

Is Modifier true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

32. Procedure.statusReason

Definition

Captures the reason for the current state of the procedure.

Short Orsak till status

Comments

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.

Control 0..1

For example codes, see ProcedureNotPerformedReason(SNOMED-CT)
(example to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason|4.0.1)

A code that identifies the reason a procedure was not performed.

Is Modifier false

Must Support true

Summary true

Alternate Names Suspended Reason, Cancelled Reason

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

34. Procedure.category

Definition

Kategorisering av aktivitetstyp (t.ex. kirurgisk, diagnostisk, terapeutisk).

TKB-källa: Kan härledas från activityGroup.activity.code

Short Kategori

Control 0..1

For example codes, see ProcedureCategoryCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-category|4.0.1)

A code that classifies a procedure for searching, sorting and display purposes.

Is Modifier false

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

36. Procedure.code

Definition

Kod för aktiviteten, typiskt KVÅ (Klassifikation av vårdåtgärder).

Svenska kodsystem:

KVÅ: urn:oid:1.2.752.116.1.1.1.1.4 (http://www.socialstyrelsen.se/kva)
SNOMED CT Procedure Codes
Lokala kodsystem via OID

TKB-källa: activityGroup.activity.code

code.code: TKB activity.code.code
code.codeSystem: TKB activity.code.codeSystem
code.displayName: TKB activity.code.displayName

Short Aktivitetskod (KVÅ eller annan klassifikation)

Control 1..1

For example codes, see ProcedureCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-code|4.0.1)

A code to identify a specific procedure .

Is Modifier false

Must Support true

Summary true

Requirements

0..1 to account for primarily narrative only resources.

Alternate Names type

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

38. Procedure.subject

Definition

Referens till patienten som aktiviteten utfördes på.

TKB-källa: activityGroup.patient.id (personnummer eller samordningsnummer)

Short Patient

Control 1..1

Type Reference(Patient Base Inera)

Is Modifier false

Must Support true

Summary true

Alternate Names patient

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

40. Procedure.encounter

Definition

Referens till vårdkontakt där aktiviteten utfördes.

Short Vårdkontakt

Comments

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.

Control 0..1

Type Reference(Encounter Base Inera)

Is Modifier false

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

42. Procedure.performed[x]

Definition

Tidpunkt eller period då aktiviteten utfördes.

performedDateTime: Om start == slut (enskild tidpunkt)
performedPeriod: Om start != slut (tidsperiod)

TKB-källa: activityGroup.activity.time

time.start → performedPeriod.start
time.end → performedPeriod.end Format: ÅÅÅÅMMDDttmmss

Short Utförandetid

Comments

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.

Control 0..1

Type Choice of: dateTime, Period, string, Age, Range

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

44. Procedure.recorder

Definition

Vem som registrerade aktiviteten i systemet.

TKB-källa: Kan härledas från metadata eller Provenance-resurs

Short Registrerare

Control 0..1

Type Reference(PractitionerRole Base Inera, Patient Base Inera, RelatedPerson)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

46. Procedure.asserter

Definition

Individual who is making the procedure statement.

Short Attestant

Control 0..1

Type Reference(PractitionerRole Base Inera, Patient Base Inera, RelatedPerson)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

48. Procedure.performer

Definition

Person(er), enhet(er) eller organisation(er) som utförde aktiviteten.

TKB-källa: activityGroup.performerRole, activityGroup.additionalParticipant

Short Utförare

Control 0..*

BackboneElement

Is Modifier false

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

50. Procedure.performer.id

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Unique id for inter-element referencing

Control 0..1

string

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

52. Procedure.performer.extension

Definition

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.

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

54. 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 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).

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

56. Procedure.performer.function

Definition

Utförarens roll vid aktiviteten.

Svenska kodsystem:

KV Befattning: urn:oid:1.2.752.129.2.2.1.4

TKB-källa: activityGroup.performerRole.code

Short Roll/funktion

Control 0..1

For example codes, see ProcedurePerformerRoleCodes
(example to http://hl7.org/fhir/ValueSet/performer-role|4.0.1)

A code that identifies the role of a performer of the procedure.

Is Modifier false

Must Support true

Summary true

Requirements

Allows disambiguation of the types of involvement of different performers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

58. Procedure.performer.actor

Definition

Referens till utförare.

TKB-källa:

activityGroup.performerRole.person.id (HSA-ID för utförande person)
activityGroup.additionalParticipant.person
activityGroup.additionalParticipant.device

Short Utförare (person/enhet)

Control 1..1

Type Reference(PractitionerRole Base Inera, Organization Base Inera, Device, Patient Base Inera, RelatedPerson)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Requirements

A reference to Device supports use cases, such as pacemakers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

60. Procedure.performer.onBehalfOf

Definition

Referens till organisation (vårdgivare) som utföraren representerar.

TKB-källa: activityGroup.performerRole.careUnit.careGiver (vårdgivare HSA-ID)

Short Organisation (vårdgivare)

Control 0..1

Type Reference(Organization Base Inera)

Is Modifier false

Must Support true

Summary false

Requirements

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

62. Procedure.location

Definition

Plats där aktiviteten utfördes.

TKB-källa:

activityGroup.performerRole.careUnit (vårdenhet)
activityGroup.additionalParticipant.location

Short Plats

Control 0..1

Type Reference(Location)

Is Modifier false

Must Support true

Summary true

Requirements

Ties a procedure to where the records are likely kept.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

64. Procedure.reasonCode

Definition

The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Short Indikation (kodad)

Comments

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 | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Control 0..*

For example codes, see ProcedureReasonCodes
(example to http://hl7.org/fhir/ValueSet/procedure-reason|4.0.1)

A code that identifies the reason a procedure is required.

Is Modifier false

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

66. Procedure.reasonReference

Definition

Referens till tillstånd eller observation som motiverar aktiviteten.

Short Indikation (referens)

Comments

It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). 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 | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Control 0..*

Type Reference(Condition, Observation, Procedure, DiagnosticReport, DocumentReference)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

68. Procedure.bodySite

Definition

Anatomisk plats där aktiviteten utfördes.

TKB-källa: activityGroup.activity.targetSite

Short Anatomisk plats

Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Control 0..*

For example codes, see SNOMEDCTBodyStructures
(example to http://hl7.org/fhir/ValueSet/body-site|4.0.1)

Codes describing anatomical locations. May include laterality.

Is Modifier false

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

70. Procedure.outcome

Definition

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Short Utfall

Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Control 0..1

For example codes, see ProcedureOutcomeCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-outcome|4.0.1)

An outcome of a procedure - whether it was resolved or otherwise.

Is Modifier false

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

72. Procedure.report

Definition

This could be a histology result, pathology report, surgical report, etc.

Short Rapport

Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Control 0..*

Type Reference(DiagnosticReport, DocumentReference, Composition)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

74. Procedure.complication

Definition

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.

Short Komplikation (kodad)

Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Control 0..*

For example codes, see Condition/Problem/DiagnosisCodes
(example to http://hl7.org/fhir/ValueSet/condition-code|4.0.1)

Codes describing complications that resulted from a procedure.

Is Modifier false

Must Support true

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

76. Procedure.complicationDetail

Definition

Any complications that occurred during the procedure, or in the immediate post-performance period.

Short Komplikationsdetalj (referens)

Control 0..*

Type Reference(Condition)

Is Modifier false

Must Support true

Summary false

Requirements

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

78. Procedure.followUp

Definition

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.

Short Uppföljning

Control 0..*

For example codes, see ProcedureFollowUpCodes(SNOMEDCT)
(example to http://hl7.org/fhir/ValueSet/procedure-followup|4.0.1)

Specific follow up required for a procedure e.g. removal of sutures.

Is Modifier false

Must Support true

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

80. Procedure.note

Definition

Fritextkommentar om aktiviteten.

TKB-källa: activityGroup.activity.description

Short Kommentar

Control 0..*

Annotation

Is Modifier false

Must Support true

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

82. Procedure.focalDevice

Definition

Utrustning/device som användes vid aktiviteten.

TKB-källa: activityGroup.additionalParticipant.device

Short Använd utrustning

Control 0..*

BackboneElement

Is Modifier false

Must Support true

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

84. Procedure.focalDevice.id

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Unique id for inter-element referencing

Control 0..1

string

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

86. Procedure.focalDevice.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

88. Procedure.focalDevice.modifierExtension

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

90. Procedure.focalDevice.action

Definition

The kind of change that happened to the device during the procedure.

Short Åtgärd med utrustning

Control 0..1

The codes SHOULD be taken from ProcedureDeviceActionCodes
(preferred to http://hl7.org/fhir/ValueSet/device-action|4.0.1)

A kind of change that happened to the device during the procedure.

Is Modifier false

Must Support true

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

92. Procedure.focalDevice.manipulated

Definition

The device that was manipulated (changed) during the procedure.

Short Utrustning (referens)

Control 1..1

Type Reference(Device)

Is Modifier false

Must Support true

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

94. Procedure.usedReference

Definition

Identifies medications, devices and any other substance used as part of the procedure.

Short Använt material/läkemedel (referens)

Comments

For devices actually implanted or removed, use Procedure.device.

Control 0..*

Type Reference(Device, Medication, Substance)

Is Modifier false

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary false

Requirements

Used for tracking contamination, etc.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

96. Procedure.usedCode

Definition

Identifies coded items that were used as part of the procedure.

Short Använt material/läkemedel (kodat)

Comments

For devices actually implanted or removed, use Procedure.device.

Control 0..*

For example codes, see FHIRDeviceTypes
(example to http://hl7.org/fhir/ValueSet/device-kind|4.0.1)

Codes describing items used during a procedure.