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Procedure

The SHR Lab domain contains definitions related to laboratory measurements, specifically measurements involving specimens.

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

AssociatedStudy

The clinical trial or other formal study related to this procedure.

Value:  Study A clinical trial or similar research study. Reference: list of FDA data elements describing a research study: prsinfo.clinicaltrials.gov/definitions.html

DirectSite

The site where the procedure is performed.

Value:  BodySite 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.

HIVScreeningTestPerformed [Entry]

The performance of a HIV Screening Test. Results will be in an accompanying observation.

Based On LaboratoryProcedurePerformed

Type must be from HIVScreeningTestCodeVS
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HIVScreeningTestRequested [Entry]

A request for a rapid HIV screening test.

Based On LaboratoryProcedureRequested

Type must be from HIVScreeningTestCodeVS
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HIVSupplementalTestPerformed [Entry]

The performance of supplement HIV test, following up an initial screening. Results are in the form of an observation.

Based On LaboratoryProcedurePerformed

Type must be from HIVSupplementalTestCodeVS
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

HIVSupplementalTestRequested [Entry]

A request for a confirmatory or additional test for HIV infection.

Based On LaboratoryProcedureRequested

Type must be from HIVSupplementalTestCodeVS
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ImagingAction

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

Based On ProcedureAction

ImagingSubstance 0 or more Substance used for this imaging procedure such as a contrast agent.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
ActionContext required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ImagingProcedurePerformed [Entry]

No Description

Based On ImagingAction

ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
ImagingSubstance 0 or more Substance used for this imaging procedure such as a contrast agent.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ImagingProcedureRequested [Entry]

No Description

Based On ImagingAction

ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
ImagingSubstance 0 or more Substance used for this imaging procedure such as a contrast agent.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

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.

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:  BodySite 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.

LaboratoryProcedure

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

Based On ProcedureAction

Type must be from http://hl7.org/fhir/ValueSet/observation-codes
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
ActionContext required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

LaboratoryProcedurePerformed [Entry]

No Description

Based On LaboratoryProcedure

ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Type must be from http://hl7.org/fhir/ValueSet/observation-codes
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

LaboratoryProcedureRequested [Entry]

No Description

Based On LaboratoryProcedure

ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Type must be from http://hl7.org/fhir/ValueSet/observation-codes
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Category is laboratory
optional A class or division of people or things having particular shared characteristics
Specimen optional Sample for analysis
Device optional 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.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
Annotation 0 or more An added or follow-up note, often after the fact, that contains metadata about who made the statement and when.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ProcedureAction

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 Action

Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
ActionContext required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ProcedureNotPerformed [Entry]

No Description

Based On ProcedureAction

ActionContext must be a NotPerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ProcedurePerformed [Entry]

No Description

Based On ProcedureAction

ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ProcedureRequested [Entry]

No Description

Based On ProcedureAction

ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RequestedContext
         where  Priority must be from http://hl7.org/fhir/ValueSet/request-priority
PartOf not used The larger entity that this is a portion of.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

ProcedureRequestedAgainst [Entry]

No Description

Based On ProcedureAction

ActionContext must be a RequestedAgainstContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SpecimenCollectionAction

Attribution specific to the collection of a specimen.

Based On ProcedureAction

AmountOrSize 0 or more The quantity of specimen collected
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
ActionContext required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SpecimenCollectionPerformed [Entry]

No Description

Based On SpecimenCollectionAction

ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
PerformedContext
         where  Participant must be a Practitioner
BodySite optional A location or structure in the body, including tissues, regions, cavities, and spaces, for example, right elbow, or left ventricle of the heart.
AmountOrSize 0 or more The quantity of specimen collected
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SpecimenCollectionRequested [Entry]

No Description

Based On SpecimenCollectionAction

ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
AmountOrSize 0 or more The quantity of specimen collected
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

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.

SurgicalProcedure

A surgical action, independent of action context.

Based On ProcedureAction

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.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
ActionContext required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SurgicalProcedureNotPerformed [Entry]

No Description

Based On SurgicalProcedure

ActionContext must be a NotPerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
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.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SurgicalProcedurePerformed [Entry]

No Description

Based On SurgicalProcedure

ActionContext must be a PerformedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
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.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SurgicalProcedureRequested [Entry]

No Description

Based On SurgicalProcedure

ActionContext must be a RequestedContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
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.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

SurgicalProcedureRequestedAgainst [Entry]

No Description

Based On SurgicalProcedure

ActionContext must be a RequestedAgainstContext
required The ontological status of the intervention, e.g., performed/not performed, requested/not requested.
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.
Type from http://hl7.org/fhir/us/core/ValueSet/us-core-procedure-code
(if covered)
required The most specific code (lowest level term) describing the kind or sort of thing being represented.
Subject must be a Patient
required The person or thing that this entry relates to, usually the Person of Record. 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, finding, condition, or intervention.
BodySite 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.
AssociatedStudy optional The clinical trial or other formal study related to this procedure.
PartOf must be a ProcedurePerformed
optional The larger entity that this is a portion of.
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.
RelatedEncounter optional If content was generated during a patient encounter, related encounter is the encounter where the information was gained.
Author optional The person or organization who created the entry and is responsible for (and may certify) the content.
Informant optional The person or entity that provided the information in the entry, as distinct from who created the entry, e.g. the subject (patient), medical professional, family member, device or software program.

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.