Guidance

This Procedure profile is used in conjunction with the COVID-19 Encounter profile and SARS CoV2 Infection profile to encode the following information and response options.

The response options are encoded as follows using:

• COVID-19 Encounter to specify the class of a medical encounter (home, inpatient, intensive care),
• SARS CoV2 Infection to specify the actual infection, which is referenced in Encounter.diagnosis.condition,
• COVID-19 Oxygen Therapy to indicate an oxygen therapy, if performed.

This profile of a FHIR Procedure is derived from the Procedure profile of the Medical Informatics Initiative (MII).

• Snapshot Table
• Snapshot Table (Must Support)
• Differential Table
• Text Summary

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	Profile_MII_ProcedureProzedur	An action that is being or was performed on a patient
id	SΣ	0..1	string	Logical id of this artifact
meta	SΣ	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
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	SΣ	0..1	uri	Identifies where the resource comes from
profile	SΣ	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) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
ProzedurDokumentationsdatum	S	0..1	dateTime	Dokumentationsdatum der Prozedur URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum
Durchfuehrungsabsicht	S	0..1	Coding	Optional Extensions Element URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Binding: ValueSet_MII_Durchfuehrungsabsicht (required)
Slices for modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
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	ΣI	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	ΣI	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣ	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	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	SΣ	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
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
Slices for coding	Σ	0..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:sct	SΣ	0..1	Coding	Code defined by a terminology system Binding: ValueSet_MII_SnomedProcedure-Category (preferred) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		0..1	code	Symbol in syntax defined by the system
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
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
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	SΣI	1..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
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
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:system
coding:ops	SΣ	0..1	​?pkp-2?	A reference to a code defined by a terminology system Binding: OpsVS (required)
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
seitenlokalisation		0..1	Coding	Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
seitenlokalisation	S	0..1	Coding	Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
system	SΣ	1..1	uri	Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops
version	SΣ	1..1	string	Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
code	SΣI	1..1	code	Der OPS-Code Example Einfacher OPS-Code: 5-470
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
coding:sct	SΣ	1..1	Coding	Code defined by a terminology system Binding: ValueSet_MII_SnomedProcedureCodes (required) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		1..1	string	Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20210731
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 57485005
display		1..1	string	Representation defined by the system Fixed Value: Oxygen therapy (procedure)
userSelected		0..1	boolean	If this coding was chosen directly by the user
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
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	ΣI	1..1	Reference(Patient | Group)	A reference from one resource to another
encounter	SΣI	0..1	Reference(COVID-19 Encounter)	Encounter created as part of
Slices for performed[x]	SΣ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	SΣ	0..1	dateTime	When the procedure was performed
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
data-absent-reason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.
value		0..1	dateTime	Primitive value for dateTime
recorder	ΣI	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	ΣI	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
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
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	ΣI	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf	I	0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	ΣI	0..1	Reference(Location)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	SΣI	1..*	Reference(SARS CoV2 Infection)	The justification that the procedure was performed
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (extensible): Codes describing anatomical locations. May include laterality.
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	I	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	I	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
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
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	I	1..1	Reference(Device)	Device that was changed
usedReference	I	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

Name	Flags	Card.	Type	Description & Constraints
Procedure	I	0..*	Profile_MII_ProcedureProzedur	An action that is being or was performed on a patient
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
ProzedurDokumentationsdatum		0..1	dateTime	Dokumentationsdatum der Prozedur URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum
Durchfuehrungsabsicht		0..1	Coding	Optional Extensions Element URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Binding: ValueSet_MII_Durchfuehrungsabsicht (required)
status	?!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.
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.
coding:sct	Σ	0..1	Coding	Code defined by a terminology system Binding: ValueSet_MII_SnomedProcedure-Category (preferred) Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
system	Σ	1..1	uri	Identity of the terminology system
code	Σ	1..1	code	Symbol in syntax defined by the system
code	ΣI	1..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:system
coding:ops	Σ	0..1	​?pkp-2?	A reference to a code defined by a terminology system Binding: OpsVS (required)
seitenlokalisation		0..1	Coding	Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
system	Σ	1..1	uri	Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops
version	Σ	1..1	string	Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
code	ΣI	1..1	code	Der OPS-Code
coding:sct	Σ	1..1	Coding	Code defined by a terminology system Binding: ValueSet_MII_SnomedProcedureCodes (required) Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		1..1	string	Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20210731
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 57485005
display		1..1	string	Representation defined by the system Fixed Value: Oxygen therapy (procedure)
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: http://snomed.info/sct
code	Σ	1..1	code	Symbol in syntax defined by the system
encounter	ΣI	0..1	Reference(COVID-19 Encounter)	Encounter created as part of
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	0..1	dateTime	When the procedure was performed
data-absent-reason		0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.
reasonReference	ΣI	1..*	Reference(SARS CoV2 Infection)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (extensible): Codes describing anatomical locations. May include laterality.
note		0..*	Annotation	Additional information about the procedure
Documentation for this format

​This structure is derived from Profile_MII_ProcedureProzedur

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Profile_MII_ProcedureProzedur	An action that is being or was performed on a patient
code
coding:sct		1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		1..1	string	Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20210731
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 57485005
display		1..1	string	Representation defined by the system Fixed Value: Oxygen therapy (procedure)
encounter	S	0..1	Reference(COVID-19 Encounter)	Encounter created as part of
performedDateTime		0..1	dateTime	When the procedure was performed
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
​ data-absent-reason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.
reasonReference	S	1..*	Reference(SARS CoV2 Infection)	The justification that the procedure was performed
Documentation for this format