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cimi.procedure

The CIMI procedure domain contains contexts, topics, and statements related to procedures.

Access

The route used to access the site of a procedure. It is used to distinguish open, closed, and percutaneous procedures.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

AmountOrSize

The quantity of specimen collected

Value:  SimpleQuantity A quantity where the comparator is not used, as defined in FHIR

DirectSite

The site where the procedure is performed.

Value:  AnatomicalLocation A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.

DirectSiteCode

The site where the procedure is performed.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

FHIRProcedureParticipant

Constraints participants to classes that are accepted by FHIR as actors in procedures.

Based On Participant

Value:  Choice required
         |  Practitioner A person who practices a healing art.
         |  Organization A social or legal structure formed by human beings.
         |  Patient A person in the role of a patient, including extended demographic information about the subject of this health record.
         |  RelatedPerson A person in a role defined in relationship to a patient
         |  Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
ParticipationType optional The role played by the participant engaged in the action, for example, as the attending physician, surgical assistant, etc.
ParticipationPeriod optional The point in time or span of time the participant is involved.
OnBehalfOf optional The party represented by the actual participant.

ImagingProcedurePerformedStatement [Entry]

No Description

Based On ProcedurePerformedStatement

StatementTopic must be a ImagingProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedurePerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

ImagingProcedureRequestedStatement [Entry]

No Description

Based On ProcedureRequestedStatement

StatementTopic must be a ImagingProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedureRequestedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

ImagingProcedureTopic

Experimental class for an imaging procedure. This class is still incomplete at this time.

Based On ProcedureTopic

ImagingSubstance 0 or more Substance used for this imaging procedure such as a contrast agent.
TopicCode from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The concept representing the finding or action that is the topic of the statement. For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.
AnatomicalLocation 0 or more A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
PartOf must be a ProcedurePerformedStatement
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Category optional A class or division of people or things having particular shared characteristics
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Reason optional The justification for an action or non-action, conclusion, opinion, etc.
Method optional The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Precondition 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
InputFinding 0 or more Patient findings expected for the performance of the specified procedure. For instance, an x-ray of a fracture prior to a surgical procedure for a bone fracture.
Indication 0 or more Conditions or situations where the procedure is recommended. In the Performed context, the actual indication should be reported.
Device 0 or more A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Location optional A position, site, or point in space where something can be found.

ImagingSubstance

Substance used for this imaging procedure such as a contrast agent.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

Indication

Conditions or situations where the procedure is recommended. In the Performed context, the actual indication should be reported.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

IndirectDevice

An indirect device used for this procedure.

Value:  Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.

IndirectDeviceCode

An indirect device used for this procedure.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

IndirectSite

The indirect site for this procedure.

Value:  AnatomicalLocation A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.

IndirectSiteCode

The indirect site for this procedure.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

InputFinding

Patient findings expected for the performance of the specified procedure. For instance, an x-ray of a fracture prior to a surgical procedure for a bone fracture.

Value:  FindingStatement Any clinical statement representing a finding.

LaboratoryProcedurePerformedStatement [Entry]

No Description

Based On ProcedurePerformedStatement

StatementTopic must be a LaboratoryProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedurePerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

LaboratoryProcedureRequestedStatement [Entry]

No Description

Based On ProcedureRequestedStatement

StatementTopic must be a LaboratoryProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedureRequestedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

LaboratoryProcedureTopic

A procedure performed on a collected specimen such as a blood panel or a biopsy. C0456984

Based On ProcedureTopic

TopicCode must be from http://hl7.org/fhir/ValueSet/observation-codes
required The concept representing the finding or action that is the topic of the statement. For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional A specimen is a substance, physical object, or collection of objects, that the laboratory considers a single discrete, uniquely identified unit that is the subject of one or more steps in the laboratory workflow. A specimen may include multiple physical pieces as long as they are considered a single unit within the laboratory workflow. A specimen results from one to many specimen collection procedures, and may be contained in multiple specimen containers. Specimen may have one or more processing activities.
AnatomicalLocation 0 or more A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
PartOf must be a ProcedurePerformedStatement
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Reason optional The justification for an action or non-action, conclusion, opinion, etc.
Method optional The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Precondition 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
InputFinding 0 or more Patient findings expected for the performance of the specified procedure. For instance, an x-ray of a fracture prior to a surgical procedure for a bone fracture.
Indication 0 or more Conditions or situations where the procedure is recommended. In the Performed context, the actual indication should be reported.
Device 0 or more A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Location optional A position, site, or point in space where something can be found.

OutputFinding

Patient findings documented during the performance of the procedure.

Value:  FindingStatement Any clinical statement representing a finding.

ProcedureNotPerformedContext

The not performed context with constraints applicable to procedures, namely, the request must be a procedure request.

Based On NotPerformedContext

RelatedRequest must be a ProcedureRequestedStatement
optional The proposal, order, or plan that is partly or wholly fulfilled by the performance of this act.
NonOccurrenceTimeOrPeriod required The point in time or span of time in which something did not happen.
Reason 0 or more The justification for an action or non-action, conclusion, opinion, etc.
ContextCode required A code representing the ontological status of the statement, e.g., whether it exists, does not exist, is planned, etc. Attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) Concept Model context attributes: 'Finding context (attribute)' (SCTID: 408729009) and 'Procedure context (attribute)' (SCTID: 408730004). The range allowed for this attribute shall be consistent with the SNOMED CT concept model specification for SWEC.

ProcedureNotPerformedStatement [Entry]

No Description

Based On ActionNotPerformedStatement

SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementTopic must be a ProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
StatementContext must be a ProcedureNotPerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
ProcedureNotPerformedContext
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

ProcedurePerformedContext

The performed context with constraints applicable to procedures.

Based On PerformedContext

Participant must be a FHIRProcedureParticipant
0 or more An entity (usually a Practitioner, Patient, or Organization but potentially a device or other entity) that participates in a healthcare task or activity.
         where  OnBehalfOf must be a Organization
The party represented by the actual participant.
Status must be from http://hl7.org/fhir/ValueSet/event-status
required The current standing or state.
RelatedRequest must be a ProcedureRequestedStatement
0 or more The proposal, order, or plan that is partly or wholly fulfilled by the performance of this act.
OutputFinding 0 or more Patient findings documented during the performance of the procedure.
OccurrenceTimeOrPeriod required The point in time or span of time in which something happens.
Encounter optional A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
Method optional The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Facility optional Services and space and equipment provided for a particular purpose; a building or place that provides a particular service or is used for a particular industry. Could be a clinical site, community site, or a mobile facility.
Outcome optional The result of performing an action or behavior, for example, an adverse reaction or new finding.
Reason 0 or more The justification for an action or non-action, conclusion, opinion, etc.
ContextCode required A code representing the ontological status of the statement, e.g., whether it exists, does not exist, is planned, etc. Attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) Concept Model context attributes: 'Finding context (attribute)' (SCTID: 408729009) and 'Procedure context (attribute)' (SCTID: 408730004). The range allowed for this attribute shall be consistent with the SNOMED CT concept model specification for SWEC.

ProcedurePerformedStatement [Entry]

No Description

Based On ActionPerformedStatement

SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementTopic must be a ProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
StatementContext must be a ProcedurePerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

ProcedureRequestedAgainstStatement [Entry]

No Description

Based On ActionRequestedAgainstStatement

SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementTopic must be a ProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
StatementContext must be a RequestedAgainstContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

ProcedureRequestedContext

The requested context with additional constraints applicable to procedures.

Based On RequestedContext

PriorityRank must be from http://hl7.org/fhir/ValueSet/request-priority
optional An indication of the importance of an action.
Status must be from http://hl7.org/fhir/ValueSet/request-status
required The current standing or state.
Encounter optional A description of an interaction between a patient and healthcare provider(s) for the purpose of providing healthcare service(s) or assessing the health status of a patient.
RequestIntent required Indicates the level of authority/intentionality associated with the request and where the request fits into the workflow chain.
ExpectedPerformanceTime optional When an action should be done. If the action is a series or recurs (e.g. daily blood sugar testing in the morning) then a Timing can be used to describe the periodicity.
ExpectedPerformerType optional What type of party should carry out the testing.
ExpectedPerformer optional Who should carry out the tests. For example, the patient or caregiver.
ExpectedMethod optional The method that should be used to carry out the action.
PerformerInstructions optional Information for the performer of the test, if needed.
PatientInstructions optional Information for the patient, such as, where to get the test, how to prepare for the test, etc.
CommunicationMethod optional This is the method the provider used to communicate. Examples include: Written, Telephoned, Verbal, Electronically Entered, Policy, Service Correction, Duplicate, etc. 'Code indicating the origin of the prescription.' - NCPDP Telecommunication (Field 419-DJ, Data Dictionary 201104). Possible values include: Written; Telephone; Electronic; Facsimile; Pharmacy; Not Known.
Reason 0 or more The justification for an action or non-action, conclusion, opinion, etc.
ContextCode required A code representing the ontological status of the statement, e.g., whether it exists, does not exist, is planned, etc. Attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) Concept Model context attributes: 'Finding context (attribute)' (SCTID: 408729009) and 'Procedure context (attribute)' (SCTID: 408730004). The range allowed for this attribute shall be consistent with the SNOMED CT concept model specification for SWEC.

ProcedureRequestedStatement [Entry]

No Description

Based On ActionRequestedStatement

SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementTopic must be a ProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
StatementContext must be a ProcedureRequestedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

ProcedureTopic

Description of a healthcare procedure, independent of action context. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.

Based On ActionTopic

TopicCode from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The concept representing the finding or action that is the topic of the statement. For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.
AnatomicalLocation 0 or more A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
PartOf must be a ProcedurePerformedStatement
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Category optional A class or division of people or things having particular shared characteristics
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Reason optional The justification for an action or non-action, conclusion, opinion, etc.
Method optional The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Precondition 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
InputFinding 0 or more Patient findings expected for the performance of the specified procedure. For instance, an x-ray of a fracture prior to a surgical procedure for a bone fracture.
Indication 0 or more Conditions or situations where the procedure is recommended. In the Performed context, the actual indication should be reported.
Device 0 or more A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Location optional A position, site, or point in space where something can be found.

SpecimenCollectionPerformedStatement [Entry]

No Description

Based On ProcedurePerformedStatement

StatementTopic must be a SpecimenCollectionTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
AnatomicalLocation optional A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedurePerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

SpecimenCollectionRequestedStatement [Entry]

No Description

Based On ProcedureRequestedStatement

StatementTopic must be a SpecimenCollectionTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedureRequestedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

SpecimenCollectionTopic

Base class for actions related to the collection of a specimen, independent of context.

Based On ProcedureTopic

AmountOrSize 0 or more The quantity of specimen collected
TopicCode from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The concept representing the finding or action that is the topic of the statement. For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.
AnatomicalLocation 0 or more A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
PartOf must be a ProcedurePerformedStatement
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Category optional A class or division of people or things having particular shared characteristics
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Reason optional The justification for an action or non-action, conclusion, opinion, etc.
Method optional The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Precondition 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
InputFinding 0 or more Patient findings expected for the performance of the specified procedure. For instance, an x-ray of a fracture prior to a surgical procedure for a bone fracture.
Indication 0 or more Conditions or situations where the procedure is recommended. In the Performed context, the actual indication should be reported.
Device 0 or more A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Location optional A position, site, or point in space where something can be found.

SurgicalApproach

The technique used to reach the site of the procedure. Approaches may be through the skin or mucous membrane, through an orifice or external.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

SurgicalProcedureNotPerformedStatement [Entry]

No Description

Based On ProcedureNotPerformedStatement

StatementTopic must be a SurgicalProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedureNotPerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
ProcedureNotPerformedContext
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

SurgicalProcedurePerformedStatement [Entry]

No Description

Based On ProcedurePerformedStatement

StatementTopic must be a SurgicalProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedurePerformedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

SurgicalProcedureRequestedAgainstStatement [Entry]

No Description

Based On ProcedureRequestedAgainstStatement

StatementTopic must be a SurgicalProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a RequestedAgainstContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

SurgicalProcedureRequestedStatement [Entry]

No Description

Based On ProcedureRequestedStatement

StatementTopic must be a SurgicalProcedureTopic
required Compositional and reusable grouping of clinical statement attributes that make up the clinical focus of a statement. StatementTopic class attributes are aligned with SNOMED CT Concept Model attributes when such an overlap exists. Note that this class does not include contextual attributes such as the nature of the action (ordered, proposed, planned, etc...), the nature of the patient state being described (e.g., present, suspected present, absent), and the attribution of this information (the who, when, where, how, why of the information recorded).
SubjectOfInformation must be a Patient
required The person or thing that this entry relates to, usually the Person of Record (see Entry). However, not all entries have health information specifically about the patient, but in different contexts, could refer to a fetus, family member (living or dead), device, location, organization, behavior, finding, condition, wound, or intervention. CIMI alignment: SubjectOfInformation is not a Participation -- unlike CIMI. There's no action to participate in. Participant has extra unnecessary attributes, such as 'onBehalfOf'.
StatementContext must be a ProcedureRequestedContext
required Compositional and reusable grouping of clinical statement attributes that provides the context for the topic of a clinical statement. The StatementContext class aligns with the SNOMED CT Situations with Explicit Context (SWEC) Concept Model. The StatementContext provides the expressivity required to specify that an act was performed or not performed or that a finding was asserted to be present or absent for the given subject of information. It also often holds provenance information relevant to the context of the clinical statement. It is important to note that by default the context applies to the conjunction of the attribute specified in the statement. For instance, if a clinical statement has a topic describing a rash on left arm and a context of 'absent', then the statement states that the subject of interest did not have a rash on the left arm but might have had one on the right arm.
SourceOfInformation optional The person or entity that provided the information in the entry, e.g. the subject (patient), medical professional, family member, device or software program, as distinct from who recorded the entry.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RecordStatus optional Concept indicating the state of this record, e.g., 'entered in error'.
Recorded optional The person who entered the order on behalf of another individual for example in the case of a verbal or a telephone order.
Signed optional Provenance information specific to the signing of the clinical statement.
Cosigned 0 or more Provenance information specific to the cosigning of the clinical statement.
Verified 0 or more Provenance information specific to the verification process associated with this statement (e.g., verifier, when verified, etc.)

SurgicalProcedureTopic

A surgical action, independent of action context.

Based On ProcedureTopic

DirectSite 0 or more The site where the procedure is performed.
DirectSiteCode 0 or more The site where the procedure is performed.
IndirectSite 0 or more The indirect site for this procedure.
IndirectSiteCode 0 or more The indirect site for this procedure.
SurgicalApproach 0 or more The technique used to reach the site of the procedure. Approaches may be through the skin or mucous membrane, through an orifice or external.
Access 0 or more The route used to access the site of a procedure. It is used to distinguish open, closed, and percutaneous procedures.
UsingDevice 0 or more The device used to perform the procedure.
UsingDeviceCode 0 or more The device used to perform the procedure.
UsingAccessDevice 0 or more The access device used to perform the procedure.
UsingAccessDeviceCode 0 or more The access device used to perform the procedure.
IndirectDevice 0 or more An indirect device used for this procedure.
IndirectDeviceCode 0 or more An indirect device used for this procedure.
TopicCode from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The concept representing the finding or action that is the topic of the statement. For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.
AnatomicalLocation 0 or more A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.
PartOf must be a ProcedurePerformedStatement
optional The larger entity that this is a portion of. For example, an organization might be part of a larger organization, or an encounter with a hospitalist might be part of a larger hospitalization encounter.
Category optional A class or division of people or things having particular shared characteristics
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
Reason optional The justification for an action or non-action, conclusion, opinion, etc.
Method optional The technique used to carry out an action, for example, the specific imaging technical or assessment vehicle.
Precondition 0 or more A description of the conditions or context of an observation, for example, under sedation, fasting or post-exercise. Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.
InputFinding 0 or more Patient findings expected for the performance of the specified procedure. For instance, an x-ray of a fracture prior to a surgical procedure for a bone fracture.
Indication 0 or more Conditions or situations where the procedure is recommended. In the Performed context, the actual indication should be reported.
Device 0 or more A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.
Location optional A position, site, or point in space where something can be found.

UsingAccessDevice

The access device used to perform the procedure.

Value:  Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.

UsingAccessDeviceCode

The access device used to perform the procedure.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.

UsingDevice

The device used to perform the procedure.

Value:  Device A specific durable physical device used in diagnosis or treatment. The value is the coding for a type of device, for example, a CPAP machine. The same device might be used on multiple patients.

UsingDeviceCode

The device used to perform the procedure.

Value:  CodeableConcept A set of codes drawn from different coding systems, representing the same concept.