Finnish Base Profiles
1.0.0 - trial-use Finland flag

This page is part of the Finnish Base Profiles (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: Fi Base Procedure

Official URL: https://hl7.fi/fhir/finnish-base-profiles/StructureDefinition/fi-base-procedure Version: 1.0.0
Active as of 2023-11-10 Computable Name: FiBaseProcedure

The Base profile for Finnish Procedure resource.

Scope and Usage

This profile sets minimum expectations for the Procedure resource to search and fetch current or historical procedures performed on or for a patient. It identifies which elements, code systems and value sets SHALL be present in the resource when using this profile.

Main procedure and sub-procedures

In many cases more than one procedure are being performed during one encounter. Usually this means that one of the procedures is the main procedure and others are sub-procedures. Latter ones could be performed in supporting or assisting purpose (e.g. Anaesthesia) or their task is to describe how the main procedure was performed (e.g. using robot for performing the procedure). This conjunction between different procedures is done by using partOf reference. The main procedure does not have partOf reference. Examples of this can be found from Examples page.

Code systems

Code systems that are associated with this profile are listed in a table below. It is not required to use these code systems in every situation, but rather to choose correct code systems depending on a use case if nessecary. Some explanation of using these code systems can be found from the website behind the link. The Use column descripes the element in which that particular code system can be used in Procedure resource.

Code System OID code Link Use
THL - toimenpideluokitus 1.2.246.537.6.2.2007 https://koodistopalvelu.kanta.fi/codeserver/pages/classification-view-page.xhtml?classificationKey=57&versionKey=119 Procedure.code
THL - Suun terveydenhuollon toimenpideluokitus 1.2.246.537.6.33 https://koodistopalvelu.kanta.fi/codeserver/pages/classification-view-page.xhtml?classificationKey=58&versionKey=79 Procedure.code
AR/YDIN - Toimenpiteen tyyppi 1.2.246.537.6.601 https://koodistopalvelu.kanta.fi/codeserver/pages/classification-view-page.xhtml?classificationKey=763&versionKey=903 Procedure.code
Kuntaliitto - Radiologinen tutkimus- ja toimenpideluokitus 1.2.246.537.6.4 https://koodistopalvelu.kanta.fi/codeserver/pages/classification-view-page.xhtml?classificationKey=44&versionKey=118 Procedure.code

NOTE: While writing this profile SNOMED code system is not widely used in Finland since adopting the code system is still in progess. More information about the subject can be found on Terminology page. Nevertheless SNOMED codes SHOULD be used if possible in a faced use case.

THL toimenpideluokitus is based on Nordic Classification of Surgical Procedures (NCSP) which can be found in here.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... partOf Σ0..*Reference(Fi Base Procedure | FI Base Observation | FI Base MedicationAdministration)Part of referenced event
... subject Σ1..1Reference(FI Base Patient | Group)Who the procedure was performed on
... encounter Σ0..1Reference(FI Base Encounter)Encounter created as part of
... recorder Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Person who asserts this procedure
... location Σ0..1Reference(FI Base Location)Where the procedure happened
... reasonReference Σ0..*Reference(FI Base Condition | FI Base Observation | Fi Base Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... complicationDetail 0..*Reference(FI Base Condition)A condition that is a result of the procedure
... usedReference 0..*Reference(Device | FI Base Medication | Substance)Items used during procedure

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.statusrequiredEventStatus

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Fi Base Procedure | FI Base Observation | FI Base MedicationAdministration)Part of referenced event
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code Σ0..1CodeableConceptIdentification of the procedure
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .

... subject Σ1..1Reference(FI Base Patient | Group)Who the procedure was performed on
... encounter Σ0..1Reference(FI Base Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(FI Base Practitioner | FI Base PractitionerRole | FI Base Organization | FI Base Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(FI Base Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(FI Base Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(FI Base Condition | FI Base Observation | Fi Base Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report 0..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..*Reference(FI Base Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | FI Base Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codeexampleProcedureCodes(SNOMEDCT)
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from Procedure

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... partOf Σ0..*Reference(Fi Base Procedure | FI Base Observation | FI Base MedicationAdministration)Part of referenced event
... subject Σ1..1Reference(FI Base Patient | Group)Who the procedure was performed on
... encounter Σ0..1Reference(FI Base Encounter)Encounter created as part of
... recorder Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Person who asserts this procedure
... location Σ0..1Reference(FI Base Location)Where the procedure happened
... reasonReference Σ0..*Reference(FI Base Condition | FI Base Observation | Fi Base Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... complicationDetail 0..*Reference(FI Base Condition)A condition that is a result of the procedure
... usedReference 0..*Reference(Device | FI Base Medication | Substance)Items used during procedure

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.statusrequiredEventStatus

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Fi Base Procedure | FI Base Observation | FI Base MedicationAdministration)Part of referenced event
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ0..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.

... code Σ0..1CodeableConceptIdentification of the procedure
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .

... subject Σ1..1Reference(FI Base Patient | Group)Who the procedure was performed on
... encounter Σ0..1Reference(FI Base Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(FI Base Patient | RelatedPerson | FI Base Practitioner | FI Base PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(FI Base Practitioner | FI Base PractitionerRole | FI Base Organization | FI Base Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(FI Base Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(FI Base Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(FI Base Condition | FI Base Observation | Fi Base Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report 0..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..*Reference(FI Base Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | FI Base Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleProcedureCategoryCodes(SNOMEDCT)
Procedure.codeexampleProcedureCodes(SNOMEDCT)
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorProcedureIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron