Patient Procedure
A procedure performed on a patient - an actual event or a report of a past procedure by a non-practitioner, generally a patient.
For reported rather than actual-event information, if specific attribute values are not available, corresponding free text descriptions can be entered instead as clinical annotation(s).
For example, Procedure Tolerance Narrative shall be documented as clinical annotation.
Since reported information is provided by a non-practitioner, expectations about its accuracy are low, unlike for actual (procedure) event information whose source is a health care practitioner or a computer record. Thus, although the information may sometimes be accurate (e.g., when a patient has access to a clinician- or computer-generated procedure report), it may also be incomplete and inaccurate, as some patients may not recall their medical history precisely.
Appears in
Constraints
- Mandatory (Procedure Code, if Patient Procedure is a Health Care Service Event).
Stereotype(s)
n/a
Attributes
| Attribute | Type | Multiplicity | Attribute note |
|---|---|---|---|
| Procedure Code | Codeable Concept | 0..1 | Uniquely specifies a procedure (e.g., "repair of femoral hernia by Henry approach").
This attribute is mandatory for procedure events.
Value Set: https://fhir.infoway-inforoute.ca/ValueSet/procedurecode
Alternate Value Set: Canadian Classification of Health Interventions (CCI): recommended supporting classification.
https://secure.cihi.ca/estore/productFamily.htm?pf=PFC4851&lang=en&media=0 |
| Procedure Category Code | Codeable Concept | 0..1 | Uniquely specifies a category which classifies the procedure, in particular for searching, sorting, and display purposes (e.g., "Surgical Procedure").
Value Set: To be developed. |
| Patient Procedure Identifier | Identifier | 0..1 | Business identifier(s) assigned to the procedure by the performer or other actors or systems. |
| Patient Procedure Occurrence Date Time | Date Time | 0..1 | The date and, if known, the time when a procedure performed actually occurred or was reported as having occurred.
If Patient Procedure is a Health Care Service Event (i.e., actually recorded in EMR, rather than simply reported by a non-clinician), then this attribute must be:
equal to Health Care Service Event Period.Start Date Time (usually)
or
(later than (>) Health Care Service Event Period.Start Date Time and
earlier than (<) Health Care Service Event Period.End Date Time if specified). |
| Patient Procedure Status Code | Codeable Concept | 1 | Uniquely specifies the status of a procedure on a patient (e.g., preparation, in progress, completed, not-done, stopped).
For reported procedures, if not otherwise specified, may default to completed.
Value Set: https://hl7.org/fhir/R4/valueset-event-status.html |
| Patient Procedure Status Reason Code | Codeable Concept | 0..1 | Uniquely specifies the reason for the status of the procedure on a patient (e.g., not wanted, not offered).
Status reason is especially relevant when procedure status indicates an exceptional state (e.g., procedure not done).
Value Set: To be developed. |
| Patient Procedure Body Site Code | Codeable Concept | 0..* | Uniquely specifies the anatomical location(s) (body site(s)) of the patient where the procedure was performed.
Value Set: https://fhir.infoway-inforoute.ca/ValueSet/anatomicaloracquiredbodystructurecode |
| Patient Procedure Tolerance Code | Codeable Concept | 0..1 | Uniquely specifies the tolerance of a patient to a procedure, i.e., how the patient responded to it (e.g., "Tolerated well, no immediate complications").
Procedure tolerance may indicate that complications have occurred, without providing additional detail, which shall be documented through the Periprocedure Event concept.
Value Set: To be developed. |
| Patient Post-Procedure Instruction Code | Codeable Concept | 0..* | Uniquely specifies procedure follow-up instruction(s) to the patient (e.g., removal of sutures).
Value Set: To be developed. |
| Patient Procedure Information Source Code | Codeable Concept | 0..1 |
Relationships
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How to cite:
Canadian Institute for Health Information. Patient Procedure. Accessed November 02, 2026.
