The FHIR profiles used for the Procedures List
Heading Description
The details of any procedures performed.
The following FHIR profiles are used to form the Personal comment List structure:
- CareConnect-List-1
- CareConnect-Procedure-1
- CareConnect-Practitioner-1
- CareConnect-PractitionerRole-1
The following profiles are referenced from the Patient demographics list structure:
Procedures Structure
Maternity data standard Mapping to FHIR profiles
Mapping Overview
| Data Standard Element | FHIR Resource Mapping | FHIR Element |
| Date/time | Observation | performed.performedDate |
| ODS/ORD Site Code | Organization | identifier |
| Name | Practitioner | name |
| SDS Job Role Name | PractitionerRole | code |
| Procedure | Procedure | code |
| Anatomical site | Procedure | bodySite |
| Laterality | Procedure | bodySite |
| Complications related to procedure | Procedure | complication |
| Specific anaesthesia issues | Procedure | Extension-CareConnect-AnaestheticIssues-1.value[x] |
| Comment | Procedure | note |
The following tables detail how to populate the FHIR resources and the mapping to the Maternity data standard.
Mapping for Procedures List
| > | Level 1 | List Resource | > | Level 2 | CareConnect-List-1 | > | Level 3 | None |
| View Used FHIR Elements | View All FHIR Elements |
| Name | Card. | Conformance | Type | Description, Constraints and mapping for Implementation |
|---|---|---|---|---|
| List | Information summarized from a list of other resources Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource Constraint (lst-2): The deleted flag can only be used if the mode of the list is “changes” Constraint (lst-1): A list can only have an emptyReason if it is empty |
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| - id | 0..1 | Optional | Id | Logical id of this artifact |
| - meta | 0..1 | Mandatory | Meta | Metadata about the resource The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-List-1' |
| - identifier | 0..* | Required | Identifier | Business identifier An identifier for this Procedures List |
| - - system | 1..1 | Required | Uri | The namespace for the identifier value The system from which the identifier came |
| - - value | 1..1 | Mandatory | String | The value that is unique A value for the identifier |
| - - assigner | 0..1 | Optional | Reference | Organization that issued id (may be just text) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Optional | CareConnect-Organization-1 | |||
| - - - reference | 0..1 | Optional | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Optional | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Optional | String | Text alternative for the resource |
| - status | 1..1 | Mandatory | Code | current : retired : entered-in-error Binding (required): The current state of the list ListStatus The status of the list MUST contain the value 'current' |
| - mode | 1..1 | Mandatory | Code | working : snapshot : changes Binding (required): The processing mode that applies to this list ListMode The mode of the list MUST contain the value 'snapshot' |
| - title | 0..1 | Mandatory | String | Descriptive name for the list This MUST contain the value 'Procedures' Mapping to Maternity data item = 'PSRB Heading Procedures' |
| - code | 0..1 | Mandatory | CodeableConcept | What the purpose of this list is Binding (preferred): What the purpose of a list is CareConnect-ListCode-1 The PRSB heading for this list. Note: for Maternity the value stated below is used which is not from the preferred value set |
| - - coding | 0..* | Mandatory | Coding | Code defined by a terminology system The SNOMED CT concept for the PRSB heading type |
| - - - system | 0..1 | Mandatory | Uri | Identity of the terminology system This MUST contain the value 'http://snomed.info/sct' |
| - - - code | 0..1 | Mandatory | Code | Symbol in syntax defined by the system This MUST contain the value 'tbc' |
| - - - display | 0..1 | Mandatory | String | Representation defined by the system This MUST contain the value 'Procedures' Mapping to Maternity data item = 'PSRB Heading Procedures' |
| - subject | 0..1 | Mandatory | Reference | If all resources have the same subject Constraint (ref-1): SHALL have a contained resource if a local reference is provided This is a reference to the Patient who is the subject of the list. |
| Mandatory | CareConnect-Patient-1 | This is the subject of the Procedures List. This MUST use the CareConnect patient profile. See patient resource reference for information on how to populate the resource. |
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| - - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL A reference to the patient resource included in the Patient demographics list within the FHIR Bundle. Note the Patient demographics list is mandatory in the FHIR bundle |
| - date | 0..1 | Mandatory | dateTime | When the list was prepared This MUST contain a system date to indicate when the list created or updated |
| - note | 0..* | Optional | Annotation | Comments about the list |
| - - author[x] | 0..1 | Optional | Reference | Individual responsible for the annotation Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Optional | CareConnect-Practitioner-1 | |||
| Optional | String | Who authored the comment on the list. | ||
| - - time | 0..1 | Required | dateTime | When the annotation was made |
| - - text | 1..1 | Required | String | The annotation - text content |
| - entry | 0..* | Mandatory | BackboneElement | Entries in the list The entries MUST be as per the diagram for this PRSB headings list with the Procedures resource being the focal resource. |
| - - date | 0..1 | Required | dateTime | When item added to list The SHOULD contain a system time of when the item was added to the list. |
| - - item | 1..1 | Required | Reference | Actual entry Constraint (ref-1): SHALL have a contained resource if a local reference is provided A reference to a Procedure resource included in the list |
| - - - reference | 0..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL |
Mapping for Procedures List Procedure
| > | Level 1 | Procedure Resource | > | Level 2 | CareConnect-Procedure-1 | > | Level 3 | None |
| View Used FHIR Elements | View All FHIR Elements |
| Name | Card. | Conformance | Type | Description, Constraints and mapping for Implementation |
|---|---|---|---|---|
| Procedure | An action that is being or was performed on a patient Constraint (dom-2): If the resource is contained in another resource, it SHALL NOT contain nested Resources Constraint (dom-1): If the resource is contained in another resource, it SHALL NOT contain any narrative Constraint (dom-4): If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated Constraint (dom-3): If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource Constraint (pro-1): Reason not done is only permitted if notDone indicator is true |
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| - id | 0..1 | Optional | Id | Logical id of this artifact |
| - meta | 0..1 | Required | Meta | Metadata about the resource |
| - - profile | 1..1 | Mandatory | Uri | Profiles this resource claims to conform to The value attribute of the profile element MUST contain the value 'https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Procedure-1' |
| - extension (anaestheticIssues) | 0..1 | Required | Extension-CareConnect-AnaestheticIssues-1 | Details of any adverse reaction to any anaesthetic agents Constraint (ext-1): Must have either extensions or value[x], not both Mapping to Digital Maternity data item = 'Specific anaesthaesia issues' |
| - identifier | 0..* | Required | Identifier | External Identifiers for this procedure An identifier for this Procedure |
| - - system | 1..1 | Mandatory | Uri | The namespace for the identifier value The system from which the identifier came |
| - - value | 1..1 | Mandatory | String | The value that is unique A value for the identifier |
| - - assigner | 0..1 | Optional | Reference | Organization that issued id (may be just text) Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Optional | CareConnect-Organization-1 | |||
| - - - reference | 0..1 | Optional | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Optional | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Optional | String | Text alternative for the resource |
| - status | 1..1 | Mandatory | Code | preparation : in-progress : suspended : aborted : completed : entered-in-error : unknown Binding (required): A code specifying the state of the procedure. EventStatus |
| - notDone | 0..1 | Optional | Boolean | True if procedure was not performed as scheduled Default Value: false |
| - notDoneReason | 0..1 | Optional | CodeableConcept | Reason procedure was not performed Binding (example): A code that identifies the reason a procedure was not performed. Procedure Not Performed Reason (SNOMED-CT) |
| - - coding | 0..* | Optional | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Optional | Uri | Identity of the terminology system |
| - - - code | 0..1 | Optional | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Optional | String | Representation defined by the system |
| - - - userSelected | 0..1 | Optional | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Optional | String | Plain text representation of the concept |
| - category | 0..1 | Optional | CodeableConcept | Classification of the procedure Binding (example): A code that classifies a procedure for searching, sorting and display purposes. Procedure Category Codes (SNOMED CT) |
| - - coding | 0..* | Optional | Coding | Code defined by a terminology system |
| - - - system | 0..1 | Optional | Uri | Identity of the terminology system |
| - - - code | 0..1 | Optional | Code | Symbol in syntax defined by the system |
| - - - display | 0..1 | Optional | String | Representation defined by the system |
| - - - userSelected | 0..1 | Optional | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Optional | String | Plain text representation of the concept |
| - code | 1..1 | Mandatory | CodeableConcept | Identification of the procedure Binding (preferred): A code to identify a specific procedure. Procedure Codes (SNOMED CT) Mapping for Digital Maternity data item = 'Procedure' |
| - - coding (snomedCT) | 1..1 | Mandatory | Coding | Code defined by a terminology system Binding (extensible): A code from the SNOMED Clinical Terminology UK. CareConnect-ProcedureCode-1 |
| - - extension (snomedCTDescriptionID) | 0..1 | Optional | Extension-coding-sctdescid | The SNOMED CT Description ID for the display Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system |
| - - - display | 1..1 | Mandatory | String | Representation defined by the system |
| - - - userSelected | 0..1 | Optional | Boolean | If this coding was chosen directly by the user |
| - subject | 1..1 | Mandatory | Reference | Who the procedure was performed on Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Mandatory | CareConnect-Patient-1 | |||
| - - reference | 1..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Optional | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Optional | String | Text alternative for the resource |
| - context | 0..1 | Optional | Reference | Encounter or episode associated with the procedure Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Optional | EpisodeOfCare | |||
| Optional | CareConnect-Encounter-1 | |||
| - - reference | 0..1 | Optional | String | Literal reference, Relative, internal or absolute URL |
| - - identifier | 0..1 | Optional | Identifier | Logical reference, when literal reference is not known |
| - - display | 0..1 | Optional | String | Text alternative for the resource |
| - performed[x] | 1..1 | Mandatory | dateTime | Date/Period the procedure was performed Mapping for Digital Maternity data item = 'Date/time' |
| - performer | 0..* | Required | BackboneElement | The people who performed the procedure |
| - - role | 0..1 | Optional | CodeableConcept | The role the actor was in Binding (example): A code that identifies the role of a performer of the procedure. Procedure Performer Role Codes |
| - - - coding | 0..* | Optional | Coding | Code defined by a terminology system |
| - - - - system | 0..1 | Optional | Uri | Identity of the terminology system |
| - - - - code | 0..1 | Optional | Code | Symbol in syntax defined by the system |
| - - - - display | 0..1 | Optional | String | Representation defined by the system |
| - - - - userSelected | 0..1 | Optional | Boolean | If this coding was chosen directly by the user |
| - - - text | 0..1 | Optional | String | Plain text representation of the concept |
| - - actor | 1..1 | Mandatory | Reference | The reference to the practitioner Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Optional | Device | |||
| Optional | CareConnect-Organization-1 | |||
| Mandatory | CareConnect-Practitioner-1 | |||
| - - - reference | 1..1 | Mandatory | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Optional | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Optional | String | Text alternative for the resource |
| - - onBehalfOf | 0..1 | Required | Reference | Organization the device or practitioner was acting for Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Required | CareConnect-Organization-1 | |||
| - - - reference | 0..1 | Required | String | Literal reference, Relative, internal or absolute URL |
| - - - identifier | 0..1 | Optional | Identifier | Logical reference, when literal reference is not known |
| - - - display | 0..1 | Optional | String | Text alternative for the resource |
| - bodySite | 0..* | Optional | CodeableConcept | Target body sites Binding (example): Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures Mapping for Digital Maternity data item = 'Anatomical site' and 'Laterality' |
| - - coding (snomedCT) | 1..1 | Mandatory | Coding | Code defined by a terminology system Binding (extensible): A code from the SNOMED Clinical Terminology UK. CareConnect-BodySite-1 |
| - - extension (snomedCTDescriptionID) | 0..1 | Optional | Extension-coding-sctdescid | The SNOMED CT Description ID for the display Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system |
| - - - display | 1..1 | Mandatory | String | Representation defined by the system |
| - - - userSelected | 0..1 | Optional | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Optional | String | Plain text representation of the concept |
| - complication | 0..* | Required | CodeableConcept | Complication following the procedure Binding (example): Codes describing complications that resulted from a procedure. Condition/Problem/Diagnosis Codes Mapping for Digital Maternity data item = 'Complications relating to procedure' |
| - - coding (snomedCT) | 0..1 | Required | Coding | Code defined by a terminology system Binding (required): A code from the SNOMED Clinical Terminology UK. CareConnect-ConditionCode-1 |
| - - extension (snomedCTDescriptionID) | 0..1 | Optional | Extension-coding-sctdescid | The SNOMED CT Description ID for the display Constraint (ext-1): Must have either extensions or value[x], not both |
| - - - system | 1..1 | Mandatory | Uri | Identity of the terminology system The element MUST contain the value 'http://snomed.info/sct' |
| - - - code | 1..1 | Mandatory | Code | Symbol in syntax defined by the system |
| - - - display | 1..1 | Mandatory | String | Representation defined by the system |
| - - - userSelected | 0..1 | Optional | Boolean | If this coding was chosen directly by the user |
| - - text | 0..1 | Optional | String | Plain text representation of the concept |
| - note | 0..1 | Optional | Annotation | Additional information about the procedure Mapping for Digital Maternity data item = 'Comment' |
| - - author[x] | 0..1 | Optional | Reference | Individual responsible for the annotation Constraint (ref-1): SHALL have a contained resource if a local reference is provided |
| Optional | RelatedPerson | |||
| Optional | CareConnect-Patient-1 | |||
| Optional | CareConnect-Practitioner-1 | |||
| Optional | String | |||
| - - time | 0..1 | Optional | dateTime | When the annotation was made |
| - - text | 1..1 | Mandatory | String | The annotation - text content |
Mapping for Procedures list Organization
The Procedures list details has reference(s) to the Organization resource. This means that any exchange of the Procedures list details heading data must also include the Organization Details
Mapping for Procedures list Practitioner
The Procedures list details has reference(s) to the Practitioner resource. This means that any exchange of the Procedures list details heading data must also include the Practitioner Details
Mapping for Procedures list PractitionerRole
The Procedures list details has reference(s) to the Practitioner Role resource. This means that any exchange of the Procedures list details heading data must also include the Practitioner Role Details