Procedure Detail
Information about actual or reported procedures. <br/><br/>For reported rather than actual-event information, i.e. where Reported Information is specified (as a relationship end), instead of Procedure Event: if specific attribute values are not available, corresponding free text descriptions can be entered instead, either in the free text field of the attribute (every logical data type has such a field) or in clinical notes. <br/><br/>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.<br/>
- Attributes
- Associations To
- Associations From
- Constraints
| Attribute |
Type |
|
Procedure Category Code
|
Codeable Concept
|
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Notes:
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A coded concept that specifies a category which classifies the procedure, in particular for searching, sorting, and display purposes (e.g., "Surgical Procedure"). <br/><br/><b>Value Set</b>: to be developed.<br/>
|
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Procedure Status Code
|
Codeable Concept
|
|
Notes:
|
A coded concept that specifies the status of a procedure (e.g., preparation, in progress, completed, not-done, stopped). <br/><br/><b>Value set:</b> <a href="https://hl7.org/fhir/R4/valueset-event-status.html"><font color="#0000ff"><u>https://hl7.org/fhir/R4/valueset-event-status.html</u></font></a> <br/>
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Procedure Status Reason Code
|
Codeable Concept
|
|
Notes:
|
A coded concept that specifies the reason for the status of the procedure (e.g., not wanted, not offered). <br/><br/>Status reason is especially relevant when procedure status indicates an exceptional state (e.g., procedure not done).<br/><br/><b>Value Set</b>: to be developed.<br/>
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Procedure Tolerance Code
|
Codeable Concept
|
|
Notes:
|
A coded concept that specifies the tolerance of a patient to a procedure, i.e. how the patient responded to it (e.g. "Tolerated well, no immediate complications"). <br/><br/>Procedure tolerance may indicate that complications have occurred, without providing additional detail, which shall be documented through the Periprocedure Event concept.<br/><br/><b>Value Set</b>: to be developed.<br/>
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Procedure Tolerance Description
|
String
|
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Notes:
|
A free text description of a patient's tolerance to a procedure, i.e. how the patient responded to it.<br/><br/>May be entered instead of Procedure Tolerance Code when no code in the available value set(s) adequately captures the information to be conveyed. May also be entered in addition to the code if extra information about tolerance needs to be documented.<br/><br/>Procedure tolerance may indicate that complications have occurred, without providing additional detail, which shall be documented through the Periprocedure Event concept.<br/>
|
|
| Constraint |
| Mandatory: XOR(Procedure Event, Reported Procedure)
|
