FHIR Procedure Resource (R4)

Procedure records an action performed on or for a patient: surgery, a diagnostic procedure, counselling. Element table, search parameters, example JSON and FHIRPath for FHIR R4.

FHIR Procedure Resource (R4) — part of the free FHIR Toolbox library.
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Overview

Procedure records an action performed on or for a patient: surgery, a diagnostic procedure, counselling. It captures what was done, its status, when, by whom and why. R5 renamed the time element from performed[x] to occurrence[x] and changed reasons to CodeableReference.

Elements

Element	Type	Cardinality	Description
Procedure.identifier	Identifier	0..*	External Identifiers for this procedure
Procedure.instantiatesCanonical	canonical	0..*	Instantiates FHIR protocol or definition
Procedure.instantiatesUri	uri	0..*	Instantiates external protocol or definition
Procedure.basedOn	Reference	0..*	A request for this procedure
Procedure.partOf	Reference	0..*	Part of referenced event
Procedure.status	code	1..1	preparation \| in-progress \| not-done \| on-hold \| stopped \| completed \| entered-in-error \| unknown
Procedure.statusReason	CodeableConcept	0..1	Reason for current status
Procedure.category	CodeableConcept	0..1	Classification of the procedure
Procedure.code	CodeableConcept	0..1	Identification of the procedure
Procedure.subject	Reference	1..1	Who the procedure was performed on
Procedure.encounter	Reference	0..1	Encounter created as part of
Procedure.performed[x]	dateTime \| Period \| string \| Age \| Range	0..1	When the procedure was performed
Procedure.recorder	Reference	0..1	Who recorded the procedure
Procedure.asserter	Reference	0..1	Person who asserts this procedure
Procedure.performer	BackboneElement	0..*	The people who performed the procedure
Procedure.performer.id	String	0..1	Unique id for inter-element referencing
Procedure.performer.extension	Extension	0..*	Additional content defined by implementations
Procedure.performer.modifierExtension	Extension	0..*	Extensions that cannot be ignored even if unrecognized
Procedure.performer.function	CodeableConcept	0..1	Type of performance
Procedure.performer.actor	Reference	1..1	The reference to the practitioner
Procedure.performer.onBehalfOf	Reference	0..1	Organization the device or practitioner was acting for
Procedure.location	Reference	0..1	Where the procedure happened
Procedure.reasonCode	CodeableConcept	0..*	Coded reason procedure performed
Procedure.reasonReference	Reference	0..*	The justification that the procedure was performed
Procedure.bodySite	CodeableConcept	0..*	Target body sites
Procedure.outcome	CodeableConcept	0..1	The result of procedure
Procedure.report	Reference	0..*	Any report resulting from the procedure
Procedure.complication	CodeableConcept	0..*	Complication following the procedure
Procedure.complicationDetail	Reference	0..*	A condition that is a result of the procedure
Procedure.followUp	CodeableConcept	0..*	Instructions for follow up
Procedure.note	Annotation	0..*	Additional information about the procedure
Procedure.focalDevice	BackboneElement	0..*	Manipulated, implanted, or removed device
Procedure.focalDevice.id	String	0..1	Unique id for inter-element referencing
Procedure.focalDevice.extension	Extension	0..*	Additional content defined by implementations
Procedure.focalDevice.modifierExtension	Extension	0..*	Extensions that cannot be ignored even if unrecognized
Procedure.focalDevice.action	CodeableConcept	0..1	Kind of change to device
Procedure.focalDevice.manipulated	Reference	1..1	Device that was changed
Procedure.usedReference	Reference	0..*	Items used during procedure
Procedure.usedCode	CodeableConcept	0..*	Coded items used during the procedure

Example JSON (R4)

{
  "resourceType": "Procedure",
  "id": "example",
  "status": "completed",
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "80146002",
        "display": "Appendectomy"
      }
    ]
  },
  "subject": {
    "reference": "Patient/example"
  },
  "performedDateTime": "2024-04-20T08:00:00Z"
}

FHIRPath

Procedure.code.coding.display — What was done
Procedure.status — Procedure status

Common validation errors

Using performedDateTime against R5, where the element is occurrenceDateTime.
Omitting subject or status. Both are required.
Using a Procedure for something that is a finding (an Observation) or an order (ServiceRequest).

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