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Procedure Profile

Canonical../StructureDefinition/nexus-emr-core-procedure
Statusdraft · 1.26.0
BaseProcedure (constraint)
SourceFSH · JSON

Defines the Nexus EMR FHIR profile for Procedure resources, based on CA-Core Procedure constraints, for aggregating data from multiple EMRs.

Overview

Overview

The Nexus EMR Core Procedure profile represents surgical procedures, diagnostic procedures, and therapeutic interventions performed on patients within primary care EMR systems. This profile captures comprehensive procedure details including codes, timing, performers, body sites, and outcomes across the Nexus EMR ecosystem.

Key Features

  • Flexible Procedure Coding: Supports CPT, SNOMED CT, LOINC, and source EMR codes
  • Performer Tracking: Documents who performed the procedure and their roles
  • Body Site Specification: Detailed anatomical location information
  • Outcome Documentation: Captures procedure results and complications
  • Status Management: Tracks completed, in-progress, and not-done procedures

Procedure Types

Common procedure categories include:

  • Surgical: Minor surgeries, biopsies, excisions
  • Diagnostic: Endoscopies, imaging procedures, biopsies
  • Therapeutic: Injections, physical therapy, counseling
  • Preventive: Screenings, vaccinations, health maintenance
  • Administrative: Consents, referrals, case management

Clinical Documentation

Essential elements include:

  • Procedure Code: What was performed (CPT, SNOMED CT)
  • Performance Date/Time: When the procedure occurred
  • Performer: Healthcare provider(s) who performed it
  • Body Site: Anatomical location(s) affected
  • Reason: Why the procedure was performed
  • Outcome: Result and any complications

Workflow Integration

The procedure profile supports:

  • Pre-procedure planning and consent
  • Intra-procedure documentation
  • Post-procedure follow-up
  • Complication tracking
  • Billing and coding workflows

Relationships to Other Resources

Procedures often link to:

  • Encounter: The visit during which it was performed
  • Condition: Diagnoses justifying the procedure
  • Observation: Results from diagnostic procedures
  • DiagnosticReport: Reports generated from procedures
  • ServiceRequest: Orders that initiated the procedure

Terminology bindings

Path Strength Value set
Procedure.status required event-status
Procedure.category example procedure-category