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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.

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Content

Procedure is one of the event resources in the FHIR workflow specification.

This resource is used to record the details of current and historical procedures performed on or for a patient. A procedure is an activity that is performed on, with, or for a patient as part of the provision of care. Examples include surgical procedures, diagnostic procedures, endoscopic procedures, biopsies, counseling, physiotherapy, personal support services, adult day care services, non-emergency transportation, home modification, exercise, etc. Procedures may be performed by a healthcare professional, a service provider, a friend or relative or in some cases by the patient themselves.

This resource provides summary information about the occurrence of the procedure and is not intended to provide real-time snapshots of a procedure as it unfolds, though for long-running procedures such as psychotherapy, it could represent summary level information about overall progress. The creation of a resource to support detailed real-time procedure information awaits the identification of a specific implementation use-case to share such information.

Resource Contents

Structure

Procedure Template

"resourceType" : "Procedure",
  "identifier" : [{ Identifier }], // External Identifiers for this procedure
	"code": //type of procedure
  "status" : "<code>", // R!  preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
  "statusReason" : { CodeableConcept }, // Reason for current status
	"reasonCode":text
  "subject" : { Reference(Patient|Group) }, // R!  Who the procedure was performed on
  // performed[x]: When the procedure was performed. One of these 5:
	"performedPeriod": "<period>"
  "performedDateTime" : "<dateTime>",
  "performedString" : "<string>",
	"outcome":
  "recorder" : { Reference(Patient|RelatedPerson|Practitioner|
   PractitionerRole) }, // Who recorded the procedure
  "asserter" : { Reference(Patient|RelatedPerson|Practitioner|
   PractitionerRole) }, // Person who asserts this procedure
  "performer" : [{ // The people who performed the procedure
    "actor" : { Reference(Practitioner|PractitionerRole|Organization|Patient|
    RelatedPerson|Device) }, // R!  The reference to the practitioner
  }],
  "location" : { Reference(Location) }, // Where the procedure happened

Example

{
  "resourceType": "Procedure",
  "status": "completed",
  "code": {
    "coding": [
      {
        "display": "Hospital Admission"
      }
    ]
  },
  "subject": {
    "reference": "Patient/f001"
  },
  "encounter": {
    "reference": "Encounter/f001"
  },
  "performedPeriod": {
    "start": "2011-06-26",
    "end": "2011-06-27"
  },
  "performer": [
    {
      "actor": {
        "reference": "Practitioner/f002",
        "display": "P. Voigt"
      }
    }
  ],
  "reasonCode": [
    {
      "text": "Heart valve disorder"
    }
  ],

  "outcome": {
    "text": "improved blood circulation"
  },

}

Mappings to DOH Data Set

References