FHIRResources
Procedure
| Maturity Level | Security Category | Resource Category |
|---|---|---|
| 3 | Patient | Clinical |
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.
Resource Content
Name | Required | Type | Description & Constraints |
|---|---|---|---|
| identifier | Identifier | External Identifiers for this procedure | |
| instantiatesCanonical | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | |
| instantiatesUri | uri | Instantiates external protocol or definition | |
| basedOn | Reference(CarePlan | ServiceRequest) | A request for this procedure | |
| partOf | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | |
| status | ✓ | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown |
| statusReason | CodeableConcept | Reason for current status | |
| category | CodeableConcept | Classification of the procedure | |
| code | CodeableConcept | Identification of the procedure | |
| subject | ✓ | Reference(Patient | Group) | Who the procedure was performed on |
| encounter | Reference(Encounter) | Encounter created as part of | |
| performed[x] | * | When the procedure was performed | |
| └─ performedDateTime | dateTime | When the procedure was performed | |
| └─ performedPeriod | Period | When the procedure was performed | |
| └─ performedString | string | When the procedure was performed | |
| └─ performedAge | Age | When the procedure was performed | |
| └─ performedRange | Range | When the procedure was performed | |
| recorder | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | |
| asserter | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | |
| performer | BackboneElement | The people who performed the procedure | |
| └─ function | CodeableConcept | Type of performance | |
| └─ actor | ✓ | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner |
| └─ onBehalfOf | Reference(Organization) | Organization the device or practitioner was acting for | |
| location | Reference(Location) | Where the procedure happened | |
| reasonCode | CodeableConcept | Coded reason procedure performed | |
| reasonReference | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | |
| bodySite | CodeableConcept | Target body sites | |
| outcome | CodeableConcept | The result of procedure | |
| report | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |
| complication | CodeableConcept | Complication following the procedure | |
| complicationDetail | Reference(Condition) | A condition that is a result of the procedure | |
| followUp | CodeableConcept | Instructions for follow up | |
| note | Annotation | Additional information about the procedure | |
| focalDevice | BackboneElement | Manipulated, implanted, or removed device | |
| └─ action | CodeableConcept | Kind of change to device | |
| └─ manipulated | ✓ | Reference(Device) | Device that was changed |
| usedReference | Reference(Device | Medication | Substance) | Items used during procedure | |
| usedCode | CodeableConcept | Coded items used during the procedure |
Search Parameters
| Name | Type | Description | Expression |
|---|---|---|---|
| code | token | A code to identify a procedure | Procedure.code |
| date | date | When the procedure was performed | Procedure.performed |
| identifier | token | A unique identifier for a procedure | Procedure.identifier |
| patient | reference | Search by subject - a patient | Procedure.subject.where(resolve() is Patient) |
| encounter | reference | Encounter created as part of | Procedure.encounter |
| based-on | reference | A request for this procedure | Procedure.basedOn |
| category | token | Classification of the procedure | Procedure.category |
| instantiates-canonical | reference | Instantiates FHIR protocol or definition | Procedure.instantiatesCanonical |
| instantiates-uri | uri | Instantiates external protocol or definition | Procedure.instantiatesUri |
| location | reference | Where the procedure happened | Procedure.location |
| part-of | reference | Part of referenced event | Procedure.partOf |
| performer | reference | The reference to the practitioner | Procedure.performer.actor |
| reason-code | token | Coded reason procedure performed | Procedure.reasonCode |
| reason-reference | reference | The justification that the procedure was performed | Procedure.reasonReference |
| status | token | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown | Procedure.status |
| subject | reference | Search by subject | Procedure.subject |
Scope and Usage
Overview
Procedure is one of the event resources in the FHIR workflow specification. This resource records details of current and historical procedures performed on or for a patient.
Definition
A procedure is an activity performed on, with, or for a patient as part of the provision of care. This includes:
- Clinical procedures (surgical, diagnostic, endoscopic, biopsies)
- Therapeutic services (counseling, physiotherapy)
- Support services (personal support, adult day care, non-emergency transportation)
- Lifestyle interventions (home modification, exercise)
Performers
Procedures may be performed by:
- Healthcare professionals
- Service providers
- Friends or relatives
- The patient themselves
Temporal Scope
- Provides summary information about procedure occurrence
- Not intended for real-time procedure tracking
- Can represent summary-level information for long-running procedures (e.g., psychotherapy progress)
Boundaries and Relationships
Resource Selection Guidelines
Do not use Procedure when a more specific resource exists for:
- Immunizations
- Drug administrations
- Communications
Procedure vs Communication
The distinction is based on intent:
- Communication: Simple disclosure of information
- Procedure: Activities intended to:
- Verify patient comprehension
- Change patient's mental state
- Provide training or counseling
Diagnostic Procedures
- Many diagnostic processes generate Observations and DiagnosticReports
- Procedure record needed only when capturing details about physical intervention
- Examples of relevant details:
- Anesthetic used
- Incision details
- Scope size
Procedure vs Task
Task:
- Workflow steps (cancelling orders, fulfilling orders, signing orders)
- Administrative actions (merging records, admitting patients)
Procedure:
- Actions intended to create physical or mental change
- Clinical interventions (surgery, physiotherapy, training)
- Often connected to Tasks (e.g., Task requesting ServiceRequest for Procedure)
Referenced Elements
This resource is referenced by: