CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG
1.0.0 - Release 1

CDC National Healthcare Safety Network (NHSN) Digital Quality Measures (dQM) Content Package IG - Downloaded Version 1.0.0 See the Directory of published versions

## Resource Profile: ACH Monthly Event Procedure

Official URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/ach-monthly-procedure | Version: 1.0.0
Standards status: Trial-use | Maturity Level: 1 | Computable Name: AcuteCareHospitalMonthlyReportingProcedure

This profile contains Required and Must Support data elements for reporting procedure information to the NHSN Acute Care Hospital (ACH) Monthly Digital Quality Measure. This profile is based on the HL7 FHIR® US Core Procedure Profile v3.1.1.

Usages:

- Examples for this Profile: Procedure/procedure-example-ach-monthly-pass1-central-line, Procedure/procedure-example-ach-monthly-pass1-lumbar, Procedure/procedure-example-ach-monthly-pass2-ivcf and Procedure/procedure-example-ach-monthly-pass3-transfusion

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient
id | Σ | 1..1 | id | Logical id of this artifact
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
code | S Σ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, HCPCS II, ICD-10PC, or CDT Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S Σ | 0..1 | Reference(Encounter) | Encounter created as part of
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
performed[x] | S Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
location | S Σ | 0..1 | Reference(Location) | Where the procedure happened
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
reasonCode | S Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible)
reasonReference | S Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
bodySite | S Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible)
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Procedure.status | required | EventStatus `http://hl7.org/fhir/ValueSet/event-status` From the FHIR Standard
Procedure.code | extensible | USCoreProcedureCodes `http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code`
Procedure.reasonCode | extensible | ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` From the FHIR Standard
Procedure.bodySite | extensible | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from USCoreProcedureProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient
id |  | 1..1 | id | Logical id of this artifact
meta |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:link-received-date-extension |  | 0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
subject |  |  |  |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S | 0..1 | Reference(Encounter) | Encounter created as part of
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
location | S | 0..1 | Reference(Location) | Where the procedure happened
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
reasonCode | S | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible)
reasonReference | S | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
bodySite | S | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Procedure.reasonCode | extensible | ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` From the FHIR Standard
Procedure.bodySite | extensible | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient
id | Σ | 1..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:link-received-date-extension |  | 0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
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)
statusReason | 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 | Σ | 0..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 | Procedure codes from SNOMED CT, CPT, HCPCS II, ICD-10PC, or CDT Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
encounter | S Σ | 0..1 | Reference(Encounter) | Encounter created as part of
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
performed[x] | S Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | 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 | S Σ | 0..1 | Reference(Location) | Where the procedure happened
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
reasonCode | S Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible)
reasonReference | S Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
bodySite | S Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible)
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 |  | 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

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Procedure.meta.security | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` From the FHIR Standard
Procedure.meta.tag | example | CommonTags `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` From the FHIR Standard
Procedure.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Procedure.status | required | EventStatus `http://hl7.org/fhir/ValueSet/event-status` From the FHIR Standard
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) `http://hl7.org/fhir/ValueSet/procedure-not-performed-reason` From the FHIR Standard
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-category` From the FHIR Standard
Procedure.code | extensible | USCoreProcedureCodes `http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code`
Procedure.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.encounter.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.performer.function | example | ProcedurePerformerRoleCodes `http://hl7.org/fhir/ValueSet/performer-role` From the FHIR Standard
Procedure.location.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.reasonCode | extensible | ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` From the FHIR Standard
Procedure.reasonReference.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.bodySite | extensible | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-outcome` From the FHIR Standard
Procedure.complication | example | Condition/Problem/DiagnosisCodes `http://hl7.org/fhir/ValueSet/condition-code` From the FHIR Standard
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-followup` From the FHIR Standard
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes `http://hl7.org/fhir/ValueSet/device-action` From the FHIR Standard
Procedure.usedCode | example | FHIRDeviceTypes `http://hl7.org/fhir/ValueSet/device-kind` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from USCoreProcedureProfile

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 9 elements

Extensions

This structure refers to these extensions:

- http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient
id | Σ | 1..1 | id | Logical id of this artifact
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
code | S Σ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, HCPCS II, ICD-10PC, or CDT Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S Σ | 0..1 | Reference(Encounter) | Encounter created as part of
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
performed[x] | S Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
location | S Σ | 0..1 | Reference(Location) | Where the procedure happened
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
reasonCode | S Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible)
reasonReference | S Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
bodySite | S Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible)
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Procedure.status | required | EventStatus `http://hl7.org/fhir/ValueSet/event-status` From the FHIR Standard
Procedure.code | extensible | USCoreProcedureCodes `http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code`
Procedure.reasonCode | extensible | ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` From the FHIR Standard
Procedure.bodySite | extensible | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

Differential View

This structure is derived from USCoreProcedureProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient
id |  | 1..1 | id | Logical id of this artifact
meta |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:link-received-date-extension |  | 0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
subject |  |  |  |
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S | 0..1 | Reference(Encounter) | Encounter created as part of
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
location | S | 0..1 | Reference(Location) | Where the procedure happened
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
reasonCode | S | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible)
reasonReference | S | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed
reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL
bodySite | S | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Procedure.reasonCode | extensible | ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` From the FHIR Standard
Procedure.bodySite | extensible | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient
id | Σ | 1..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:link-received-date-extension |  | 0..1 | dateTime | Received Date URL: http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
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)
statusReason | 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 | Σ | 0..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 | Procedure codes from SNOMED CT, CPT, HCPCS II, ICD-10PC, or CDT Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure
subject | S Σ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
encounter | S Σ | 0..1 | Reference(Encounter) | Encounter created as part of
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
performed[x] | S Σ | 1..1 |  | When the procedure was performed
performedDateTime |  |  | dateTime |
performedPeriod |  |  | Period |
recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure
asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | 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 | S Σ | 0..1 | Reference(Location) | Where the procedure happened
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
reasonCode | S Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (extensible)
reasonReference | S Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
bodySite | S Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (extensible)
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 |  | 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

#### Terminology Bindings

Path | Conformance | ValueSet | URI
Procedure.meta.security | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` From the FHIR Standard
Procedure.meta.tag | example | CommonTags `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` From the FHIR Standard
Procedure.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Procedure.status | required | EventStatus `http://hl7.org/fhir/ValueSet/event-status` From the FHIR Standard
Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) `http://hl7.org/fhir/ValueSet/procedure-not-performed-reason` From the FHIR Standard
Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-category` From the FHIR Standard
Procedure.code | extensible | USCoreProcedureCodes `http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code`
Procedure.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.encounter.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.performer.function | example | ProcedurePerformerRoleCodes `http://hl7.org/fhir/ValueSet/performer-role` From the FHIR Standard
Procedure.location.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.reasonCode | extensible | ProcedureReasonCodes `http://hl7.org/fhir/ValueSet/procedure-reason` From the FHIR Standard
Procedure.reasonReference.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` From the FHIR Standard
Procedure.bodySite | extensible | SNOMEDCTBodyStructures `http://hl7.org/fhir/ValueSet/body-site` From the FHIR Standard
Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-outcome` From the FHIR Standard
Procedure.complication | example | Condition/Problem/DiagnosisCodes `http://hl7.org/fhir/ValueSet/condition-code` From the FHIR Standard
Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) `http://hl7.org/fhir/ValueSet/procedure-followup` From the FHIR Standard
Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes `http://hl7.org/fhir/ValueSet/device-action` From the FHIR Standard
Procedure.usedCode | example | FHIRDeviceTypes `http://hl7.org/fhir/ValueSet/device-kind` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from USCoreProcedureProfile

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 9 elements

Extensions

This structure refers to these extensions:

- http://www.cdc.gov/nhsn/fhirportal/dqm/ig/StructureDefinition/link-received-date-extension

Maturity: 1

Other representations of profile: CSV, Excel, Schematron