| Australian Digital Health Agency FHIR Implementation Guide 1.0.0

Australian Digital Health Agency FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available versions.

### StructureDefinition: ADHA Core Procedure [Active]

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.

#### Boundaries and relationships

This profile is referenced by ADHA Core Encounter, ADHA Core Flag, and ADHA Core Procedure.

#### Formal Views of Profile Content

The official URL for this profile is:

    http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-procedure-core-1

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 builds on AUBaseProcedure.

This profile was published on 2023-04-14 04:02:01+0000 as a active by Australian Digital Health Agency.

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

- Differential Table
- Snapshot Table
- All

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: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
subject | S C | 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 | S C | 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 | S C | 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[x] | S | 0..* | Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference) | The justification that the procedure was performed
bodySite | S C | 0..* | CodeableConcept | Target body sites Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (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

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
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
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
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 | ?!S 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 | S 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 | S Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code | S Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
subject | S Σ C | 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 Σ | 0..1 | Reference(ADHA Core Encounter) | Encounter created as part of
performed[x] | S Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | S Σ C | 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 | S Σ C | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson) | 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: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
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 | S Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference | S Σ | 0..* | Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference) | The justification that the procedure was performed
bodySite | S Σ C | 0..* | CodeableConcept | Target body sites Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
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: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
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 | S | 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

Differential View

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: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
subject | S C | 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 | S C | 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 | S C | 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[x] | S | 0..* | Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference) | The justification that the procedure was performed
bodySite | S C | 0..* | CodeableConcept | Target body sites Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (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

Snapshot View

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
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.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
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
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 | ?!S 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 | S 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 | S Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code | S Σ | 1..1 | CodeableConcept | Identification of the procedure Binding: https://healthterminologies.gov.au/fhir/ValueSet/procedure-1 (extensible)
subject | S Σ C | 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 Σ | 0..1 | Reference(ADHA Core Encounter) | Encounter created as part of
performed[x] | S Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
performedString |  |  | string |
performedAge |  |  | Age |
performedRange |  |  | Range |
recorder | S Σ C | 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 | S Σ C | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Patient | ADHA Core RelatedPerson) | 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: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
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 | S Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference | S Σ | 0..* | Reference(ADHA Core Condition | ADHA Core Observation | ADHA Core Procedure | ADHA Core DocumentReference) | The justification that the procedure was performed
bodySite | S Σ C | 0..* | CodeableConcept | Target body sites Binding: https://healthterminologies.gov.au/fhir/ValueSet/body-site-1 (extensible) inv-dh-pro-04: If a coded body site is provided, at least one code shall be from SNOMED CT
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: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
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 | S | 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

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
Procedure.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
Procedure.status | required | EventStatus
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)
Procedure.code | extensible | https://healthterminologies.gov.au/fhir/ValueSet/procedure-1
Procedure.performer.function | example | ProcedurePerformerRoleCodes
Procedure.reasonCode | example | ProcedureReasonCodes
Procedure.bodySite | extensible | https://healthterminologies.gov.au/fhir/ValueSet/body-site-1
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication | example | Condition/Problem/DiagnosisCodes
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes
Procedure.usedCode | example | FHIRDeviceTypes

#### Search Parameters

None defined.