xCaliber healthCare Data Mesh

Procedure

Overview

The Procedure resource represents any diagnostic, therapeutic, or surgical event, intervention or process performed on patients.

Use Cases

  • Clinical Documentation - Record procedures performed including clinical notes, resources used, findings.
  • Billing & Reimbursement - Capture procedure details needed for accurate billing like codes, equipment, supplies.
  • Post-op Follow-up - Schedule follow-up appointments and care based on procedure protocols.
  • Clinical Decision Support - Check for appropriateness of planned procedures based on clinical rules and guidelines.
  • Resource Management - Manage medical supplies and asset utilization across procedural areas.
  • Clinical Research - Aggregate procedure data for analysis of effectiveness, safety, and outcomes.
  • Population Health - Analyze procedure trends, costs, and indications across patient cohorts.
  • Standards Adherence - Ensure procedures comply with required steps, clinical pathways, and regulatory needs.
  • Referral Coordination - Coordinate procedures needing outside specialists based on procedural complexity.
  • Patient Education - Provide patients with discharge instructions and details of their procedures.

EHR Data Model

EHRSupported?Mapped Source Object
AthenaSurgical History
ElationHistory
EpicProcedure Identifier, Procedure Provider, Procedure

Object Definition

{
  "resourceType": "Procedure",
  "id": "example",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Routine Appendectomy</div>"
  },
  "status": "completed",
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "80146002",
        "display": "Appendectomy (Procedure)"
      }
    ],
    "text": "Appendectomy"
  },
  "subject": {
    "reference": "Patient/example"
  },
  "performedDateTime": "2013-04-05",
  "recorder": {
    "reference": "Practitioner/example",
    "display": "Dr Cecil Surgeon"
  },
  "asserter": {
    "reference": "Practitioner/example",
    "display": "Dr Cecil Surgeon"
  },
  "performer": [
    {
      "actor": {
        "reference": "Practitioner/example",
        "display": "Dr Cecil Surgeon"
      }
    }
  ],
  "reasonCode": [
    {
      "text": "Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding"
    }
  ],
  "followUp": [
    {
      "text": "ROS 5 days  - 2013-04-10"
    }
  ],
  "note": [
    {
      "text": "Routine Appendectomy. Appendix was inflamed and in retro-caecal position"
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}

Data Fields

Data FieldTypeDescription
resourceTypeProcedureThis is a Procedure resource
ididThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
metaMetaThe 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.
implicitRulesuriA 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.
languagecodeThe base language in which the resource is written.
textNarrativeA 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.
containedBackboneElementThese 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.
extensionExtensionMay be used to represent additional information that is not part of the basic definition of the resource. 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.
modifierExtensionExtensionMay 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).
identifierIdentifierBusiness identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.
instantiatesCanonicalcanonicalThe 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.
instantiatesUriuriThe 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.
basedOnReferenceA reference to a resource that contains details of the request for this procedure.
partOfReferenceA larger event of which this particular procedure is a component or step.
statuscodeA code specifying the state of the procedure. Generally, this will be the in-progress or completed state.
statusReasonCodeableConceptCaptures the reason for the current state of the procedure.
categoryCodeableConceptA code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").
codeCodeableConceptThe specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").
subjectReferenceThe person, animal or group on which the procedure was performed.
encounterReferenceThe Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.
performedDateTimestringEstimated or actual date, date-time, period, or age when 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.
performedPeriodPeriodEstimated or actual date, date-time, period, or age when 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.
performedStringstringEstimated or actual date, date-time, period, or age when 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.
performedAgeAgeEstimated or actual date, date-time, period, or age when 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.
performedRangeRangeEstimated or actual date, date-time, period, or age when 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.
recorderReferenceIndividual who recorded the record and takes responsibility for its content.
asserterReferenceIndividual who is making the procedure statement.
performerBackboneElementLimited to "real" people rather than equipment.
performer.idstringUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
performer.extensionExtensionMay 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.
performer.modifierExtensionExtensionMay 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).
performer.functionCodeableConceptDistinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.
performer.actorReferenceThe practitioner who was involved in the procedure.
performer.onBehalfOfReferenceThe organization the device or practitioner was acting on behalf of.
locationReferenceThe location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.
reasonCodeCodeableConceptThe coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.
reasonReferenceReferenceThe justification of why the procedure was performed.
bodySiteCodeableConceptDetailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.
outcomeCodeableConceptThe outcome of the procedure - did it resolve the reasons for the procedure being performed?
reportReferenceThis could be a histology result, pathology report, surgical report, etc.
complicationCodeableConceptAny 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.
complicationDetailReferenceAny complications that occurred during the procedure, or in the immediate post-performance period.
followUpCodeableConceptIf 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.
noteAnnotationAny other notes and comments about the procedure.
focalDeviceBackboneElementA device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.
focalDevice.idstringUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
focalDevice.extensionExtensionMay 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.
focalDevice.modifierExtensionExtensionMay 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).
focalDevice.actionCodeableConceptThe kind of change that happened to the device during the procedure.
focalDevice.manipulatedReferenceThe device that was manipulated (changed) during the procedure.
usedReferenceReferenceIdentifies medications, devices and any other substance used as part of the procedure.
usedCodeCodeableConceptIdentifies coded items that were used as part of the procedure.

Extensions

NameURL
TYPEhttp://xcaliber-fhir/structureDefinition/type
RANKhttp://xcaliber-fhir/structureDefinition/rank
DELETED_DATEhttp://xcaliber-fhir/structureDefinition/deleted-date
BILLING_DATEhttp://xcaliber-fhir/structureDefinition/billing-date
BILLING_STATUShttp://xcaliber-fhir/structureDefinition/billing-status
MODIFIERShttp://xcaliber-fhir/structureDefinition/modifiers
SECTIONNOTEhttp://xcaliber-fhir/structureDefinition/section-note
NOTELASTMODIFIEDBYhttp://xcaliber-fhir/structureDefinition/note-last-modified-by
NOTELASTMODIFIEDDATETIMEhttp://xcaliber-fhir/structureDefinition/note-last-modified-date-time

Operations & APIs

Procedure-GET

Procedure-POST

Procedure ID-GET

Procedure ID-PUT

PractitionerRole ID-DELETE

Procedure Export-POST