Identificador lógico deste artefato

Metadados sobre o recurso

Conjunto de regras sob as quais este conteúdo foi criado

Idioma do conteúdo do recurso

Resumo do texto do recurso em linguagem natural

Recursos contidos em linha

Extensão que não pode ser ignorada

Identificadores externos para este item

Instâncias ou definições do protocolo FHIR

Instâncias externas do protocolo ou definições

Uma requisição para o procedimento

Parte do evento referenciado

Um código que especifica o estado do procedimento:preparação | em andamento | não realizado | em espera | paraso | concluído | digitado com erro | desconhecido

Motivo para o estado atual

Classificação do procedimento. Exemplo: um código que classifica um procedimento para fins de pesquisa, classificação e exibição

Um conceito que referncia uma terminologia ou apenas texto

Em quem o procedimento foi realizado

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Referência literal, URL relativa, interna ou absoluta

Tipo ao qual a referência se refere (por exemplo, Paciente)

Referência lógica, quando a referência literal não é conhecida

Texto alternativo para o recurso

Contato assistencial descrito nesta Composition

Quando o procedimento foi realizado

Identificador exclusivo para referência entre elementos

Quem registrou o procedimento

Pessoa que afirma este procedimento

As pessoas que realizaram o procedimento

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Tipo de performance

Referência do profissional

Organização para a qual o dispositivo ou profissional estava atuando

Onde aconteceu o procedimento

Código do motivo do procedimento realizado

A justificativa de que o procedimento foi realizado

Conceito - referência a uma terminologia ou apenas texto

Resultado do procedimento

Qualquer relatório resultante do procedimento

Complicação após o procedimento

Uma condição que é resultado da complicação do procedimento

Instruções para acompanhamento

Informações adicionais sobre o procedimento

Dispositivo manipulado, implantado ou removido

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Tipo de alteração no dispositivo

Dispositivo que foi alterado

Itens usados ​durante o procedimento

Itens codificados usados ​​durante o procedimento

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Identificador lógico deste artefato

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Metadados sobre o recurso

Conjunto de regras sob as quais este conteúdo foi criado

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Idioma do conteúdo do recurso

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

Resumo do texto do recurso em linguagem natural

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Recursos contidos em linha

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Extensão que não pode ser ignorada

Identificadores externos para este item

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Instâncias ou definições do protocolo FHIR

Instâncias externas do protocolo ou definições

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Uma requisição para o procedimento

Parte do evento referenciado

The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Um código que especifica o estado do procedimento:preparação | em andamento | não realizado | em espera | paraso | concluído | digitado com erro | desconhecido

The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the procedure.

Motivo para o estado atual

This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

A code that identifies the reason a procedure was not performed.

Classificação do procedimento. Exemplo: um código que classifica um procedimento para fins de pesquisa, classificação e exibição

A code that classifies a procedure for searching, sorting and display purposes.

Um conceito que referncia uma terminologia ou apenas texto

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

SNOMED CT procedure code set or a code for absent/unknown procedure

0..1 to account for primarily narrative only resources.

Em quem o procedimento foi realizado

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Referência literal, URL relativa, interna ou absoluta

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Tipo ao qual a referência se refere (por exemplo, Paciente)

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Aa resource (or, for logical models, the URI of the logical model).

Referência lógica, quando a referência literal não é conhecida

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Texto alternativo para o recurso

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Contato assistencial descrito nesta Composition

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Quando o procedimento foi realizado

Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Identificador exclusivo para referência entre elementos

Provides a reason why the performed is missing.

Quem registrou o procedimento

Pessoa que afirma este procedimento

As pessoas que realizaram o procedimento

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Tipo de performance

A code that identifies the role of a performer of the procedure.

Allows disambiguation of the types of involvement of different performers.

Referência do profissional

A reference to Device supports use cases, such as pacemakers.

Organização para a qual o dispositivo ou profissional estava atuando

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Onde aconteceu o procedimento

Ties a procedure to where the records are likely kept.

Código do motivo do procedimento realizado

Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

A code that identifies the reason a procedure is required.

A justificativa de que o procedimento foi realizado

It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Conceito - referência a uma terminologia ou apenas texto

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Resultado do procedimento

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

An outcome of a procedure - whether it was resolved or otherwise.

Qualquer relatório resultante do procedimento

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Complicação após o procedimento

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Codes describing complications that resulted from a procedure.

Uma condição que é resultado da complicação do procedimento

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Instruções para acompanhamento

Specific follow up required for a procedure e.g. removal of sutures.

Informações adicionais sobre o procedimento

Dispositivo manipulado, implantado ou removido

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Tipo de alteração no dispositivo

A kind of change that happened to the device during the procedure.

Dispositivo que foi alterado

Itens usados ​durante o procedimento

For devices actually implanted or removed, use Procedure.device.

Used for tracking contamination, etc.

Itens codificados usados ​​durante o procedimento

For devices actually implanted or removed, use Procedure.device.

Codes describing items used during a procedure.

An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy.

Identificador lógico deste artefato

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Metadados sobre o recurso

Conjunto de regras sob as quais este conteúdo foi criado

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Idioma do conteúdo do recurso

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

Resumo do texto do recurso em linguagem natural

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Recursos contidos em linha

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May 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.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Extensão que não pode ser ignorada

Identificadores externos para este item

This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number.

Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers.

Instâncias ou definições do protocolo FHIR

Instâncias externas do protocolo ou definições

This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier.

Uma requisição para o procedimento

Parte do evento referenciado

The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration).

Um código que especifica o estado do procedimento:preparação | em andamento | não realizado | em espera | paraso | concluído | digitado com erro | desconhecido

The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the procedure.

Motivo para o estado atual

This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here.

A code that identifies the reason a procedure was not performed.

Classificação do procedimento. Exemplo: um código que classifica um procedimento para fins de pesquisa, classificação e exibição

A code that classifies a procedure for searching, sorting and display purposes.

Um conceito que referncia uma terminologia ou apenas texto

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

SNOMED CT procedure code set or a code for absent/unknown procedure

0..1 to account for primarily narrative only resources.

Em quem o procedimento foi realizado

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Referência literal, URL relativa, interna ou absoluta

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Tipo ao qual a referência se refere (por exemplo, Paciente)

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Aa resource (or, for logical models, the URI of the logical model).

Referência lógica, quando a referência literal não é conhecida

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Texto alternativo para o recurso

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Contato assistencial descrito nesta Composition

This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

Quando o procedimento foi realizado

Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone.

Identificador exclusivo para referência entre elementos

May 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.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Provides a reason why the performed is missing.

Quem registrou o procedimento

Pessoa que afirma este procedimento

As pessoas que realizaram o procedimento

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Tipo de performance

A code that identifies the role of a performer of the procedure.

Allows disambiguation of the types of involvement of different performers.

Referência do profissional

A reference to Device supports use cases, such as pacemakers.

Organização para a qual o dispositivo ou profissional estava atuando

Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action.

Onde aconteceu o procedimento

Ties a procedure to where the records are likely kept.

Código do motivo do procedimento realizado

Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

A code that identifies the reason a procedure is required.

A justificativa de que o procedimento foi realizado

It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition | Observation | Procedure | DiagnosticReport | DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure.

Conceito - referência a uma terminologia ou apenas texto

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Resultado do procedimento

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

An outcome of a procedure - whether it was resolved or otherwise.

Qualquer relatório resultante do procedimento

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Complicação após o procedimento

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Codes describing complications that resulted from a procedure.

Uma condição que é resultado da complicação do procedimento

This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure.

Instruções para acompanhamento

Specific follow up required for a procedure e.g. removal of sutures.

Informações adicionais sobre o procedimento

Dispositivo manipulado, implantado ou removido

Identificador exclusivo para referência entre elementos

Conteúdo adicional definido por implementações

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas

Tipo de alteração no dispositivo

A kind of change that happened to the device during the procedure.

Dispositivo que foi alterado

Itens usados ​durante o procedimento

For devices actually implanted or removed, use Procedure.device.

Used for tracking contamination, etc.

Itens codificados usados ​​durante o procedimento

For devices actually implanted or removed, use Procedure.device.

Codes describing items used during a procedure.