AKTIN Notfalldokumentation
1.0.0 - ballot
AKTIN Notfalldokumentation
1.0.0 - ballot
AKTIN Notfalldokumentation - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://aktin.org/fhir/StructureDefinition/aktin-pr-rontgenwirbelsaule-durchgefuhrt | Version: 1.0.0 | |||
| Active as of 2025-06-12 | Computable Name: AKTIN_PR_rontgenwirbelsaule_durchgefuhrt | |||
Wurde ein Röntgen der Wirbelsäule durchgeführt?
Hinweise, bitte beachten
Dieses AKTIN-Profil zu 'Procedure' ist direkt abgeleitet vom Profil des bekannten Bausteins 'ISiKProzedur'. Es gibt die formalen Erfordernisse an, welche die AKTIN-spezifischen Eigenschaften zum existierendes Profil zusätzlich vorhanden sein müssen und welche Constraints gelten. Diese sind im 'Differential View' direkt ersichtlich.
Es dient dem Aufzeigen der semantischen Annotationen des zugrundeliegenden Konzepts und optional der Bindung der Valusets an Antwort-Auswahllisten, kodierten Zusatzinformationen und Maßeinheiten.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Procedure |
C | 0..* | ISiKProzedur(4.0.0-rc3) | An action that is being or was performed on a patient Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, proc-ISiK-1, proc-ISiK-2 |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
  Slices for extension |
S | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
   extension:Dokumentationsdatum |
S | 0..1 | dateTime | Dokumentationsdatum der Prozedur URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Slice: Unordered, Open by value:url |
 identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure |
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. Required Pattern: completed |
| category |
SΣ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
  Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system |
  coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenKategorieSCT (preferred) Required Pattern: At least the following |
 id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
 system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| code |
SΣC | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1, proc-ISiK-3 |
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system |
 coding:OPS |
SΣ | 0..1 | CodingOPS(1.5.3) | A reference to a code defined by a terminology system Binding: OPS ValueSet (required) |
  Slices for extension |
Content/Rules for all slices | |||
 extension:Seitenlokalisation |
S | 0..1 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) |
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops |
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") |
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 |
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenCodesSCT (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 79760008 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Radiography of spine (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
 text |
SΣ | 0..1 | string | Plain text representation of the concept |
 subject |
SΣC | 1..1 | Reference(Patient (AKTIN)) | Who the procedure was performed on Constraints: ref-1 |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter created as part of Constraints: ref-1 |
| performed[x] |
SΣ | 1..1 | dateTime | Zeitpunkt, wann Maßnahme durchgeführt wurde |
| note |
S | 0..* | Annotation | Additional information about the procedure |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.status | required | Pattern Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1From the FHIR Standard | |
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryFrom the FHIR Standard | |
| Procedure.category.coding:SNOMED-CT | preferred | Pattern Value: SNOMED-CT Code 363679005("Imaging")https://gematik.de/fhir/isik/ValueSet/ProzedurenKategorieSCT | |
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codeFrom the FHIR Standard | |
| Procedure.code.coding:OPS | required | OpsVShttp://fhir.de/ValueSet/bfarm/ops | |
| Procedure.code.coding:SNOMED-CT | required | Pattern Value: SNOMED-CT Code 79760008("Radiography of spine (procedure)")https://gematik.de/fhir/isik/ValueSet/ProzedurenCodesSCT |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If 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-4 | error | Procedure | If 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-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ops-regex | warning | Procedure.code.coding:OPS.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt : matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$') | |
| proc-ISiK-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden : code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists() | |
| proc-ISiK-2 | error | Procedure | Falls eine codierte Prozedur vorliegt MUSS eine kodierte Category abgebildet werden : code.coding.exists() implies category.coding.exists() | |
| proc-ISiK-3 | error | Procedure.code | Entweder MUSS eine kodierte Prozedur vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. : coding.exists().not() implies text.exists() | |
| ref-1 | error | Procedure.subject, Procedure.encounter | SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) | |
| sct-ops-1 | error | Procedure.code | Falls die Prozedur kodiert vorliegt, SOLL mindestens ein OPS oder SNOMED-CT Code angegeben werden. Liegt die Prozedur nicht kodiert vor SOLL Freitext angegeben werden. : coding.exists() implies coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() |
This structure is derived from ISiKProzedur
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
0..* | ISiKProzedur(4.0.0-rc3) | An action that is being or was performed on a patient | |
 identifier |
S | 0..* | Identifier | External Identifiers for this procedure |
| status |
1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Required Pattern: completed | |
| category |
1..1 | CodeableConcept | Classification of the procedure | |
| Slices for coding |
Content/Rules for all slices | |||
| coding:SNOMED-CT |
0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Required Pattern: At least the following | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging | |
| code |
1..1 | CodeableConcept | Identification of the procedure | |
| Slices for coding |
Content/Rules for all slices | |||
| coding:SNOMED-CT |
0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Required Pattern: At least the following | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 79760008 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Radiography of spine (procedure) | |
| subject |
1..1 | Reference(Patient (AKTIN)) | Who the procedure was performed on | |
| performed[x] |
1..1 | dateTime | Zeitpunkt, wann Maßnahme durchgeführt wurde | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | ISiKProzedur(4.0.0-rc3) | An action that is being or was performed on a patient Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, proc-ISiK-1, proc-ISiK-2 | ||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
S | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||
| extension:Dokumentationsdatum |
S | 0..1 | dateTime | Dokumentationsdatum der Prozedur URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Slice: Unordered, Open by value:url | ||||
| identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
ΣC | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure Constraints: ref-1 | ||||
| partOf |
ΣC | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event Constraints: ref-1 | ||||
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. Required Pattern: completed | ||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
SΣ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system | ||||
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenKategorieSCT (preferred) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| code |
SΣC | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1, proc-ISiK-3 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system | ||||
| coding:OPS |
SΣ | 0..1 | CodingOPS(1.5.3) | A reference to a code defined by a terminology system Binding: OPS ValueSet (required) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:Seitenlokalisation |
S | 0..1 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) | ||||
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops | ||||
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") | ||||
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenCodesSCT (required) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 79760008 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Radiography of spine (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
SΣ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
SΣC | 1..1 | Reference(Patient (AKTIN)) | Who the procedure was performed on Constraints: ref-1 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter created as part of Constraints: ref-1 | ||||
| performed[x] |
SΣ | 1..1 | dateTime | Zeitpunkt, wann Maßnahme durchgeführt wurde | ||||
| recorder |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure Constraints: ref-1 | ||||
| asserter |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure Constraints: ref-1 | ||||
| performer |
Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor |
ΣC | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| location |
ΣC | 0..1 | Reference(Location) | Where the procedure happened Constraints: ref-1 | ||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
ΣC | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed Constraints: ref-1 | ||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome |
Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report |
C | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure Constraints: ref-1 | ||||
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail |
C | 0..* | Reference(Condition) | A condition that is a result of the procedure Constraints: ref-1 | ||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note |
S | 0..* | Annotation | Additional information about the procedure | ||||
| focalDevice |
0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
C | 1..1 | Reference(Device) | Device that was changed Constraints: ref-1 | ||||
| usedReference |
C | 0..* | Reference(Device | Medication | Substance) | Items used during procedure Constraints: ref-1 | ||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Procedure.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Procedure.status | required | Pattern Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1From the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonFrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryFrom the FHIR Standard | ||||
| Procedure.category.coding:SNOMED-CT | preferred | Pattern Value: SNOMED-CT Code 363679005("Imaging")https://gematik.de/fhir/isik/ValueSet/ProzedurenKategorieSCT | ||||
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codeFrom the FHIR Standard | ||||
| Procedure.code.coding:OPS | required | OpsVShttp://fhir.de/ValueSet/bfarm/ops | ||||
| Procedure.code.coding:SNOMED-CT | required | Pattern Value: SNOMED-CT Code 79760008("Radiography of spine (procedure)")https://gematik.de/fhir/isik/ValueSet/ProzedurenCodesSCT | ||||
| Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-roleFrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomeFrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codeFrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupFrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionFrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If 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-4 | error | Procedure | If 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-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ops-regex | warning | Procedure.code.coding:OPS.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt : matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$') | |
| proc-ISiK-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden : code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists() | |
| proc-ISiK-2 | error | Procedure | Falls eine codierte Prozedur vorliegt MUSS eine kodierte Category abgebildet werden : code.coding.exists() implies category.coding.exists() | |
| proc-ISiK-3 | error | Procedure.code | Entweder MUSS eine kodierte Prozedur vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. : coding.exists().not() implies text.exists() | |
| ref-1 | error | Procedure.basedOn, Procedure.partOf, Procedure.subject, Procedure.encounter, Procedure.recorder, Procedure.asserter, Procedure.performer.actor, Procedure.performer.onBehalfOf, Procedure.location, Procedure.reasonReference, Procedure.report, Procedure.complicationDetail, Procedure.focalDevice.manipulated, Procedure.usedReference | SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) | |
| sct-ops-1 | error | Procedure.code | Falls die Prozedur kodiert vorliegt, SOLL mindestens ein OPS oder SNOMED-CT Code angegeben werden. Liegt die Prozedur nicht kodiert vor SOLL Freitext angegeben werden. : coding.exists() implies coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() |
This structure is derived from ISiKProzedur
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
C | 0..* | ISiKProzedur(4.0.0-rc3) | An action that is being or was performed on a patient Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, proc-ISiK-1, proc-ISiK-2 |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| extension:Dokumentationsdatum |
S | 0..1 | dateTime | Dokumentationsdatum der Prozedur URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Slice: Unordered, Open by value:url |
| identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure |
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. Required Pattern: completed |
| category |
SΣ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. |
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system |
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenKategorieSCT (preferred) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| code |
SΣC | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1, proc-ISiK-3 |
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system |
| coding:OPS |
SΣ | 0..1 | CodingOPS(1.5.3) | A reference to a code defined by a terminology system Binding: OPS ValueSet (required) |
| Slices for extension |
Content/Rules for all slices | |||
| extension:Seitenlokalisation |
S | 0..1 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) |
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops |
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") |
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 |
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenCodesSCT (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 79760008 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Radiography of spine (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
SΣ | 0..1 | string | Plain text representation of the concept |
| subject |
SΣC | 1..1 | Reference(Patient (AKTIN)) | Who the procedure was performed on Constraints: ref-1 |
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter created as part of Constraints: ref-1 |
| performed[x] |
SΣ | 1..1 | dateTime | Zeitpunkt, wann Maßnahme durchgeführt wurde |
| note |
S | 0..* | Annotation | Additional information about the procedure |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Procedure.status | required | Pattern Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1From the FHIR Standard | |
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryFrom the FHIR Standard | |
| Procedure.category.coding:SNOMED-CT | preferred | Pattern Value: SNOMED-CT Code 363679005("Imaging")https://gematik.de/fhir/isik/ValueSet/ProzedurenKategorieSCT | |
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codeFrom the FHIR Standard | |
| Procedure.code.coding:OPS | required | OpsVShttp://fhir.de/ValueSet/bfarm/ops | |
| Procedure.code.coding:SNOMED-CT | required | Pattern Value: SNOMED-CT Code 79760008("Radiography of spine (procedure)")https://gematik.de/fhir/isik/ValueSet/ProzedurenCodesSCT |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If 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-4 | error | Procedure | If 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-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ops-regex | warning | Procedure.code.coding:OPS.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt : matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$') | |
| proc-ISiK-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden : code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists() | |
| proc-ISiK-2 | error | Procedure | Falls eine codierte Prozedur vorliegt MUSS eine kodierte Category abgebildet werden : code.coding.exists() implies category.coding.exists() | |
| proc-ISiK-3 | error | Procedure.code | Entweder MUSS eine kodierte Prozedur vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. : coding.exists().not() implies text.exists() | |
| ref-1 | error | Procedure.subject, Procedure.encounter | SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) | |
| sct-ops-1 | error | Procedure.code | Falls die Prozedur kodiert vorliegt, SOLL mindestens ein OPS oder SNOMED-CT Code angegeben werden. Liegt die Prozedur nicht kodiert vor SOLL Freitext angegeben werden. : coding.exists() implies coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() |
Differential View
This structure is derived from ISiKProzedur
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
0..* | ISiKProzedur(4.0.0-rc3) | An action that is being or was performed on a patient | |
| identifier |
S | 0..* | Identifier | External Identifiers for this procedure |
| status |
1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Required Pattern: completed | |
| category |
1..1 | CodeableConcept | Classification of the procedure | |
| Slices for coding |
Content/Rules for all slices | |||
| coding:SNOMED-CT |
0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Required Pattern: At least the following | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging | |
| code |
1..1 | CodeableConcept | Identification of the procedure | |
| Slices for coding |
Content/Rules for all slices | |||
| coding:SNOMED-CT |
0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Required Pattern: At least the following | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 79760008 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Radiography of spine (procedure) | |
| subject |
1..1 | Reference(Patient (AKTIN)) | Who the procedure was performed on | |
| performed[x] |
1..1 | dateTime | Zeitpunkt, wann Maßnahme durchgeführt wurde | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | ISiKProzedur(4.0.0-rc3) | An action that is being or was performed on a patient Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, proc-ISiK-1, proc-ISiK-2 | ||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
S | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||
| extension:Dokumentationsdatum |
S | 0..1 | dateTime | Dokumentationsdatum der Prozedur URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Slice: Unordered, Open by value:url | ||||
| identifier |
SΣ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
ΣC | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure Constraints: ref-1 | ||||
| partOf |
ΣC | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event Constraints: ref-1 | ||||
| status |
?!SΣ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure. Required Pattern: completed | ||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
SΣ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
Σ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system | ||||
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenKategorieSCT (preferred) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| code |
SΣC | 1..1 | CodeableConcept | Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1, proc-ISiK-3 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system | ||||
| coding:OPS |
SΣ | 0..1 | CodingOPS(1.5.3) | A reference to a code defined by a terminology system Binding: OPS ValueSet (required) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| extension:Seitenlokalisation |
S | 0..1 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) | ||||
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops | ||||
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") | ||||
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:SNOMED-CT |
SΣ | 0..1 | ISiKSnomedCTCoding(4.0.2) | A reference to a code defined by a terminology system Binding: ProzedurenCodesSCT (required) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 79760008 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Radiography of spine (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
SΣ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
SΣC | 1..1 | Reference(Patient (AKTIN)) | Who the procedure was performed on Constraints: ref-1 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
SΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter created as part of Constraints: ref-1 | ||||
| performed[x] |
SΣ | 1..1 | dateTime | Zeitpunkt, wann Maßnahme durchgeführt wurde | ||||
| recorder |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure Constraints: ref-1 | ||||
| asserter |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure Constraints: ref-1 | ||||
| performer |
Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor |
ΣC | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| location |
ΣC | 0..1 | Reference(Location) | Where the procedure happened Constraints: ref-1 | ||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
ΣC | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed Constraints: ref-1 | ||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome |
Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report |
C | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure Constraints: ref-1 | ||||
| complication |
0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail |
C | 0..* | Reference(Condition) | A condition that is a result of the procedure Constraints: ref-1 | ||||
| followUp |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note |
S | 0..* | Annotation | Additional information about the procedure | ||||
| focalDevice |
0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action |
0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated |
C | 1..1 | Reference(Device) | Device that was changed Constraints: ref-1 | ||||
| usedReference |
C | 0..* | Reference(Device | Medication | Substance) | Items used during procedure Constraints: ref-1 | ||||
| usedCode |
0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Procedure.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Procedure.status | required | Pattern Value: completedhttp://hl7.org/fhir/ValueSet/event-status|4.0.1From the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonFrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryFrom the FHIR Standard | ||||
| Procedure.category.coding:SNOMED-CT | preferred | Pattern Value: SNOMED-CT Code 363679005("Imaging")https://gematik.de/fhir/isik/ValueSet/ProzedurenKategorieSCT | ||||
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codeFrom the FHIR Standard | ||||
| Procedure.code.coding:OPS | required | OpsVShttp://fhir.de/ValueSet/bfarm/ops | ||||
| Procedure.code.coding:SNOMED-CT | required | Pattern Value: SNOMED-CT Code 79760008("Radiography of spine (procedure)")https://gematik.de/fhir/isik/ValueSet/ProzedurenCodesSCT | ||||
| Procedure.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesFrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-roleFrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonFrom the FHIR Standard | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-siteFrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomeFrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codeFrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupFrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionFrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindFrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Procedure | If 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-4 | error | Procedure | If 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-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Procedure | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ops-regex | warning | Procedure.code.coding:OPS.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt : matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$') | |
| proc-ISiK-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden : code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists() | |
| proc-ISiK-2 | error | Procedure | Falls eine codierte Prozedur vorliegt MUSS eine kodierte Category abgebildet werden : code.coding.exists() implies category.coding.exists() | |
| proc-ISiK-3 | error | Procedure.code | Entweder MUSS eine kodierte Prozedur vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. : coding.exists().not() implies text.exists() | |
| ref-1 | error | Procedure.basedOn, Procedure.partOf, Procedure.subject, Procedure.encounter, Procedure.recorder, Procedure.asserter, Procedure.performer.actor, Procedure.performer.onBehalfOf, Procedure.location, Procedure.reasonReference, Procedure.report, Procedure.complicationDetail, Procedure.focalDevice.manipulated, Procedure.usedReference | SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) | |
| sct-ops-1 | error | Procedure.code | Falls die Prozedur kodiert vorliegt, SOLL mindestens ein OPS oder SNOMED-CT Code angegeben werden. Liegt die Prozedur nicht kodiert vor SOLL Freitext angegeben werden. : coding.exists() implies coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() |
This structure is derived from ISiKProzedur
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ AKTIN e.V.. Package org.aktin.notfalldokumentation#1.0.0 based on FHIR 4.0.1. Generated 2025-07-31
