Procedure FHIR Resource Proposal
Contents
- 1 Procedure
- 1.1 Owning committee name
- 1.2 Contributing or Reviewing Work Groups
- 1.3 FHIR Resource Development Project Insight ID
- 1.4 Scope of coverage
- 1.5 RIM scope
- 1.6 Resource appropriateness
- 1.7 Expected implementations
- 1.8 Content sources
- 1.9 Example Scenarios
- 1.10 Resource Relationships
- 1.11 Timelines
- 1.12 gForge Users
- 1.13 Issues
Procedure
Owning committee name
(Temporarily managed by FHIR Core with review from Patient care)
Contributing or Reviewing Work Groups
None
FHIR Resource Development Project Insight ID
Pending
Scope of coverage
An action that is performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counselling or hypnotherapy.
An Act whose immediate and primary outcome (post-condition) is the alteration of the physical or mental condition of the subject. Used to record the details of procedures performed on a patient. This includes surgical procedures, diagnostic procedures, endoscopic procedures, biopsies. It also includes group therapy, training, psycho-therapy, music therapy, etc. It does not include drug therapy, chemotherapy, radiation therapy, light therapy or other therapies where "dosage" is a primary aspect of the intervention.
Procedure specifically excludes activities whose primary activity is the introduction of medications or similar substances (Immunization, MedicationAdministration). The focus of the Procedure resource is the actual activities performed, as opposed to Observation and DiagnosticReport which may be used to capture information learned while performing a procedure. Activities whose sole purpose is to gain information without performing any significant disruption of the subject (e.g. MRI, colonoscopy, etc.) are not technically Procedures, though because of the scheduling, possibility of use of anesthetic, etc. many systems may choose to represent them as Procedures.
When capturing planned/intended procedures, CarePlan or Appointment should be used.
RIM scope
Procedure[classCode=PROC, moodCode=EVN]
Resource appropriateness
Procedures are a common activity within medical practice and recorded by most EMR systems.
Expected implementations
A part of CCDA so can be expected to be implemented by most systems that support this. There are many specialist systems (particularly for surgical procedures) that record details of procedures.
Content sources
CCDA, openEHR, Affiliate specifications, existing systems
Example Scenarios
- Appendectomy
- Biopsy
- Counselling session
Resource Relationships
The procedure resource is linked to:
- Patient resource as the subject
- Practitioner resource as the author
- DiagnosticReport for the report of the procedure
- Procedure/MedicationPrescription as related resources
It is likely the Specimen will also be included once that resource is specified.
Timelines
Expected to be balloted DSTU in September 2013
gForge Users
david_hay
Issues
- Revamped to clarify relationship to MedicationAdministration, Observation and DiagnosticReport. Also expanded examples for non-surgical procedures and gave guidance on observations typically treated as procedures.
- Need to confirm that light therapy, radiation, etc. aren't covered here. Where should ultrasound therapy live?
- Why/how would specimen relate to Procedure? As a product? Specimen now exists, so if it's in the 80%, add it.
- Need better/tighter explanation of "related resources". Related how?