BR.GOV.SAUDE.IPS.FHIR\ProcedureBRIPS - Definitions

idstring

Is Modifier false

Summary true

4. Procedure.meta

Definition

Metadados sobre o recurso.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Short Metadados sobre o recurso.Metadata about the resource

Control 0..1

Meta

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

6. Procedure.implicitRules

Definition

Conjunto de regras sob as quais este conteúdo foi criado.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Short Conjunto de regras sob as quais este conteúdo foi criado.A set of rules under which this content was created

Comments

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.

Control 0..1

uri

Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

8. Procedure.language

Definition

Idioma do conteúdo do recurso.

The base language in which the resource is written.

Short Idioma do conteúdo do recurso.Language of the resource content

Comments

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).

Control 0..1

The codes SHOULD be taken from CommonLanguageshttp://hl7.org/fhir/ValueSet/languages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional Bindings

Purpose

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

10. Procedure.text

Definition

Resumo do texto do recurso em linguagem natural.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Short Resumo do texto do recurso em linguagem natural.Text summary of the resource, for human interpretation

Comments

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.

Control 0..1

Narrative

Is Modifier false

Summary false

Alternate Names narrative, html, xhtml, display

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

12. Procedure.contained

Definition

Recursos contidos em linha.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Short Recursos contidos em linha.Contained, inline Resources

Comments

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.

Control 0..*

Resource

Is Modifier false

Summary false

Alternate Names inline resources, anonymous resources, contained resources

14. Procedure.modifierExtension

Definition

Extensão que não pode ser ignorada.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensão que não pode ser ignorada.Extensions that cannot be ignored

Comments

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.

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them

Summary false

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Names extensions, user content

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())

16. Procedure.identifier

Definition

Identificadores externos para este item.

Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server.

Short Identificadores externos para este item.External Identifiers for this procedure

Comments

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.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..*

Identifier

Is Modifier false

Summary true

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

18. Procedure.instantiatesCanonical

Definition

Instâncias ou definições do protocolo FHIR.

The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Short Instâncias ou definições do protocolo FHIR.Instantiates FHIR protocol or definition

Control 0..*

Type canonical(PlanDefinition, ActivityDefinition, Measure, OperationDefinition, Questionnaire)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

20. Procedure.instantiatesUri

Definition

Instâncias externas do protocolo ou definições.

The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure.

Short Instâncias externas do protocolo ou definições.Instantiates external protocol or definition

Comments

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

Control 0..*

uri

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

22. Procedure.basedOn

Definition

Uma requisição para o procedimento.

A reference to a resource that contains details of the request for this procedure.

Short Uma requisição para o procedimento.A request for this procedure

Control 0..*

Type Reference(CarePlan, ServiceRequest)

Is Modifier false

Summary true

Alternate Names fulfills

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

24. Procedure.partOf

Definition

Parte do evento referenciado.

A larger event of which this particular procedure is a component or step.

Short Parte do evento referenciado.Part of referenced event

Comments

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).

Control 0..*

Type Reference(ProcedureBRIPS, ObservationResultsBRIPS, MedicationAdministration, Procedure, Observation)

Is Modifier false

Summary true

Alternate Names container

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

26. Procedure.status

Definition

A code specifying the state of the procedure. Generally, this will be the in-progress or completed state.

Comments

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.

Control 1..1

The codes SHALL be taken from EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/event-status|4.0.1)

A code specifying the state of the procedure.

code

Is Modifier true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

28. Procedure.statusReason

Definition

Motivo para o estado atual.

Captures the reason for the current state of the procedure.

Short Motivo para o estado atual.Reason for current status

Comments

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.

Control 0..1

For example codes, see ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reason
(example to http://hl7.org/fhir/ValueSet/procedure-not-performed-reason)

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

Is Modifier false

Summary true

Alternate Names Suspended Reason, Cancelled Reason

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

30. Procedure.category

Definition

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

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Short Classificação do procedimento.Classification of the procedure

Control 0..1

For example codes, see ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-category
(example to http://hl7.org/fhir/ValueSet/procedure-category)

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

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

32. Procedure.code

Definition

Um conceito que referencia uma terminologia ou apenas texto.

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Short Um conceito que referencia uma terminologia ou apenas texto.Identification of the procedure

Comments

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.

Control 10..1
This element is affected by the following invariants: ele-1

The codes SHOULD be taken from For example codes, see Procedures - SNOMED CT + Absent/Unknown - IPShttp://hl7.org/fhir/ValueSet/procedure-code
(preferred to http://hl7.org/fhir/uv/ips/ValueSet/procedures-snomed-absent-unknown-uv-ips)

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

A code to identify a specific procedure .

Type CodeableConcept(Codeable Concept (IPS))

Is Modifier false

Must Support true

Requirements

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

Alternate Names type

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

34. Procedure.subject

Definition

Em quem o procedimento foi realizado.

The person, animal or group on which the procedure was performed.

Short Em quem o procedimento foi realizado.Who the procedure was performed on

Control 1..1

Type Reference(PatientBRIPS, Patient, Group)

Is Modifier false

Must Support true

Summary true

Alternate Names patient

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

36. Procedure.subject.id

Definition

Identificador exclusivo para referência entre elementos.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Identificador exclusivo para referência entre elementos.Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

38. Procedure.subject.extension

Definition

Conteúdo adicional definido por implementações.

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.

Short Conteúdo adicional definido por implementações.Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

Slicing

This element introduces a set of slices on Procedure.subject.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

40. Procedure.subject.reference

Definition

Referência literal, URL relativa, interna ou absoluta.

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Short Referência literal, URL relativa, interna ou absoluta.Literal reference, Relative, internal or absolute URL

Comments

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.

Control 10..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support true

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

42. Procedure.subject.type

Definition

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

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

Short Tipo ao qual a referência se refere (por exemplo, Paciente).Type the reference refers to (e.g. "Patient")

Comments

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.

Control 0..1

Unless not suitable, these codes SHALL be taken from ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types
(extensible to http://hl7.org/fhir/ValueSet/resource-types)

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

uri

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

44. Procedure.subject.identifier

Definition

Referência lógica, quando a referência literal não é conhecida.

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Short Referência lógica, quando a referência literal não é conhecida.Logical reference, when literal reference is not known

Comments

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).

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Identifier

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

46. Procedure.subject.display

Definition

Texto alternativo para o recurso.

Plain text narrative that identifies the resource in addition to the resource reference.

Short Texto alternativo para o recurso.Text alternative for the resource

Comments

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.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

48. Procedure.encounter

Definition

Contato assistencial descrito nesta Composition

The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated.

Short Contato assistencial descrito nesta CompositionEncounter created as part of

Comments

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.

Control 0..1

Type Reference(Encounter)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

50. Procedure.performed[x]

Definition

Quando o procedimento foi realizado.

Estimated or actual date, date-time, period, or age when the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Short Quando o procedimento foi realizado.When the procedure was performed

Comments

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.

Control 10..1

Type Choice of: dateTime, Period, string, Age, Range

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support true

Must Support Types No must-support rules about the choice of types/profiles

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

52. Procedure.performed[x].id

Definition

Identificador exclusivo para referência entre elementos.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Identificador exclusivo para referência entre elementos.Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

54. Procedure.performed[x].extension:data-absent-reason

Slice Name data-absent-reason

Definition

Provides a reason why the performed is missing.

Short performed[x] absence reason

Control 0..1

Type Extension(Data Absent Reason) (Extension Type: code)

Is Modifier false

Must Support true

Summary false

56. Procedure.recorder

Definition

Quem registrou o procedimento.

Individual who recorded the record and takes responsibility for its content.

Short Quem registrou o procedimento.Who recorded the procedure

Control 0..1

Type Reference(PatientBRIPS, RelatedPerson, PractitionerBRIPS, PractitionerRoleBRIPS, Patient, Practitioner, PractitionerRole)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

58. Procedure.asserter

Definition

Pessoa que afirma este procedimento.

Individual who is making the procedure statement.

Short Pessoa que afirma este procedimento.Person who asserts this procedure

Control 0..1

Type Reference(PatientBRIPS, RelatedPerson, PractitionerBRIPS, PractitionerRoleBRIPS, Patient, Practitioner, PractitionerRole)

Is Modifier false

Must Support false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

60. Procedure.performer

Definition

As pessoas que realizaram o procedimento.

Limited to "real" people rather than equipment.

Short As pessoas que realizaram o procedimento.The people who performed the procedure

Control 0..*

BackboneElement

Is Modifier false

Must Support false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

62. Procedure.performer.id

Definition

Identificador exclusivo para referência entre elementos.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Identificador exclusivo para referência entre elementos.Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

64. Procedure.performer.extension

Definition

Conteúdo adicional definido por implementações.

Short Conteúdo adicional definido por implementações.Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

66. Procedure.performer.modifierExtension

Definition

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas.Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

68. Procedure.performer.function

Definition

Tipo de performance.

Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist.

Short Tipo de performance.Type of performance

Control 0..1

For example codes, see ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-role
(example to http://hl7.org/fhir/ValueSet/performer-role)

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

Is Modifier false

Summary true

Requirements

Allows disambiguation of the types of involvement of different performers.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

70. Procedure.performer.actor

Definition

Referência do profissional.

The practitioner who was involved in the procedure.

Short Referência do profissional.The reference to the practitioner

Control 1..1

Type Reference(PatientBRIPS, RelatedPerson, Device - performer, observer, PractitionerBRIPS, PractitionerRoleBRIPS, OrganizationBRIPS, Practitioner, PractitionerRole, Organization, Patient, Device)

Is Modifier false

Must Support false

Summary true

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

72. Procedure.performer.onBehalfOf

Definition

Organização para a qual o dispositivo ou profissional estava atuando.

The organization the device or practitioner was acting on behalf of.

Short Organização para a qual o dispositivo ou profissional estava atuando.Organization the device or practitioner was acting for

Control 0..1

Type Reference(OrganizationBRIPS, Organization)

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

74. Procedure.location

Definition

Onde aconteceu o procedimento.

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Short Onde aconteceu o procedimentoWhere the procedure happened

Control 0..1

Type Reference(Location)

Is Modifier false

Summary true

Requirements

Ties a procedure to where the records are likely kept.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

76. Procedure.reasonCode

Definition

Código do motivo do procedimento realizado.

The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text.

Short Código do motivo do procedimento realizado.Coded reason procedure performed

Comments

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.

Control 0..*

For example codes, see ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reason
(example to http://hl7.org/fhir/ValueSet/procedure-reason)

A code that identifies the reason a procedure is required.

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

78. Procedure.reasonReference

Definition

A justificativa de que o procedimento foi realizado.

The justification of why the procedure was performed.

Short A justificativa de que o procedimento foi realizado.The justification that the procedure was performed

Comments

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.

Control 0..*

Type Reference(ConditionBRIPS, ObservationResultsBRIPS, ProcedureBRIPS, DiagnosticReportBRIPS, DocumentReference, Condition, Observation, Procedure, DiagnosticReport)

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

80. Procedure.bodySite

Definition

Conceito - referência a uma terminologia ou apenas texto.

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Short Conceito - referência a uma terminologia ou apenas texto.Target body sites

Comments

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure.

Control 0..*
This element is affected by the following invariants: ele-1

Binding For example codes, see SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-site
(example to http://hl7.org/fhir/ValueSet/body-site)

Type CodeableConcept(Codeable Concept (IPS))

Is Modifier false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

82. Procedure.outcome

Definition

Resultado do procedimento.

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

Short Resultado do procedimento.The result of procedure

Comments

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

Control 0..1

For example codes, see ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcome
(example to http://hl7.org/fhir/ValueSet/procedure-outcome)

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

Is Modifier false

Summary true

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

84. Procedure.report

Definition

Qualquer relatório resultante do procedimento.

This could be a histology result, pathology report, surgical report, etc.

Short Qualquer relatório resultante do procedimento.Any report resulting from the procedure

Comments

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.

Control 0..*

Type Reference(DiagnosticReportBRIPS, DocumentReference, CompositionBRIPS, DiagnosticReport, Composition)

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

86. Procedure.complication

Definition

Complicação após o procedimento.

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Short Complicação após o procedimento.Complication following the procedure

Comments

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

Control 0..*

For example codes, see Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-code
(example to http://hl7.org/fhir/ValueSet/condition-code)

Codes describing complications that resulted from a procedure.

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

88. Procedure.complicationDetail

Definition

Uma condição que é resultado da complicação do procedimento.

Any complications that occurred during the procedure, or in the immediate post-performance period.

Short Uma condição que é resultado da complicação do procedimento.A condition that is a result of the procedure

Control 0..*

Type Reference(ConditionBRIPS, Condition)

Is Modifier false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

90. Procedure.followUp

Definition

Instruções para acompanhamento.

If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used.

Short Instruções para acompanhamento.Instructions for follow up

Control 0..*

For example codes, see ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followup
(example to http://hl7.org/fhir/ValueSet/procedure-followup)

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

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

92. Procedure.note

Definition

Informações adicionais sobre o procedimento.

Any other notes and comments about the procedure.

Short Informações adicionais sobre o procedimento.Additional information about the procedure

Control 0..*

Annotation

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

94. Procedure.focalDevice

Definition

Dispositivo manipulado, implantado ou removido.

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Short Dispositivo manipulado, implantado ou removido.Manipulated, implanted, or removed device

Control 0..*

BackboneElement

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

96. Procedure.focalDevice.id

Definition

Identificador exclusivo para referência entre elementos.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Short Identificador exclusivo para referência entre elementos.Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

98. Procedure.focalDevice.extension

Definition

Conteúdo adicional definido por implementações.

Short Conteúdo adicional definido por implementações.Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

100. Procedure.focalDevice.modifierExtension

Definition

Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Short Extensões que não podem ser ignoradas mesmo que não sejam reconhecidas.Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

102. Procedure.focalDevice.action

Definition

Tipo de alteração no dispositivo.

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

Short Tipo de alteração no dispositivo.Kind of change to device

Control 0..1

The codes SHOULD be taken from ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-action
(preferred to http://hl7.org/fhir/ValueSet/device-action)

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

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

104. Procedure.focalDevice.manipulated

Definition

Dispositivo que foi alterado.

The device that was manipulated (changed) during the procedure.

Short Dispositivo que foi alterado.Device that was changed

Control 1..1

Type Reference(Device)

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

106. Procedure.usedReference

Definition

Itens usados durante o procedimento.

Identifies medications, devices and any other substance used as part of the procedure.

Short Itens usados durante o procedimento.Items used during procedure

Comments

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

Control 0..*

Type Reference(Device, MedicationBRIPS, Substance, Medication)

Is Modifier false

Summary false

Requirements

Used for tracking contamination, etc.

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

108. Procedure.usedCode

Definition

Itens codificados usados durante o procedimento.

Identifies coded items that were used as part of the procedure.

Short Itens codificados usados durante o procedimento.Coded items used during the procedure

Comments

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

Control 0..*

For example codes, see FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kind
(example to http://hl7.org/fhir/ValueSet/device-kind)

Codes describing items used during a procedure.

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. Procedure

Definition

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.

Short An action that is being or was performed on a patient

Control 0..*

Is Modifier false

Summary false

Invariants dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())

2. Procedure.id

Definition

Identificador lógico deste artefato.

Short Identificador lógico deste artefato.

Comments

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

Control 0..1

Is Modifier false

Summary true

4. Procedure.meta

Definition

Metadados sobre o recurso.

Short Metadados sobre o recurso.

Control 0..1