eHN Guidelines
| Data | Description | Preferred Code Systems | Arbetsgruppens ("Svensk") tolkning av informationselementet | Utvärderingsparametrar | De nationella tjänstekontrakten | ||
| * ** A.2 Patient summary body data elements | |||||||
| A.2.3.3 Procedures | Ur uppdragsbeskrivning: •Socialstyrelsens arbete med kodverk för åtgärder (KVÅ) och mappning med internationella standarder som SNOMED CT fortsätter. | ||||||
| A.2.3.3.1 Procedure description | Describes the type of procedure | SNOMED CT GPS* | Beskrivning av hur lösningen möter EDHS krav | ||||
| Bedömning | |||||||
| Täckningsgrad | |||||||
| Kvalité på informationen | |||||||
| A.2.3.3.2 Body site | Procedure target body site | SNOMED CT GPS* | Beskrivning av hur lösningen möter EDHS krav | ||||
| Bedömning | |||||||
| Täckningsgrad | |||||||
| Kvalité på informationen | |||||||
| A.2.3.3.3 Procedure date | Date when procedure was performed | ISO 8601 | Beskrivning av hur lösningen möter EDHS krav | ||||
| Bedömning | |||||||
| Täckningsgrad | |||||||
| Kvalité på informationen | |||||||
* In a foreseeable future, the suggested preferred vocabularies might be superseded or
complemented, as mentioned in Guidelines Article 11(2).
** The Preferred code system(s) has been selected based on adequacy to convey the
information using the methodology of the Subgroup on Semantics. When more alternative
international code systems are available, all are listed when it is assumed to be unlikely that
agreement can be reached short term. Mapping between code systems could be proposed for
specific use cases.
Xt-EHR Logical Model
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | ||||
| B.1.3.4 - Procedures section | Procedures section | 0 | 1 | Base | ||||||
| B.1.3.4.1 - Subsection narative | Narative content of the subsection. | 0 | 1 | string | ||||||
| B.1.3.4.2 - Procedures | Major procedures. | 1 | * | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure |
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | |||
| Procedure model | C.16 - EHDS refined base model for An action that is or was performed on or for a patient | 0 | * | ||||||
| C.16.1 - Identifier | Procedure identifier | 0 | * | Identifier | |||||
| C.16.2 - Description | Procedure specification in string form | 0 | 1 | string | |||||
| C.16.3 - Code | Code identifying the procedure | 0 | 1 | CodeableConcept | preferred | SNOMED CT | |||
| C.16.4 - Date | Date and time of the procedure or interval of its performance | 0 | 1 | dateTime Period | |||||
| C.16.5 - Performer | An actor who or what performed the procedure | 0 | * | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional) | |||||
| C.16.6 - Anatomic location | Anatomic location and laterality where the procedure was performed. This is the target site. | 0 | * | CodeableConcept | preferred | SNOMED CT, ICD-O-3 | |||
| C.16.7 - Reason | The reason why the procedure was performed. | 0 | * | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSObservation|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSProcedure) | |||||
| C.16.8 - Outcome | The outcome of the procedure - did it resolve the reasons for the procedure being performed? | 0 | 1 | CodeableConcept | preferred | SNOMED CT | |||
| C.16.9 - Complication | Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the procedure description, which will typically describe the procedure itself rather than any 'post procedure' issues. | 0 | * | CodeableConcept | preferred | ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed | |||
| C.16.10 - Device used | Device used to perform the procedure | 0 | * | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice | |||||
| C.16.11 - Focal device | Device or devices that is/are implanted, removed, or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure. | 0 | * | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice) | |||||
| C.16.12 - Location | Location where the procedure had been performed | 0 | * | https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLocation | |||||
| C.16.13 - Note | Additional information about the procedure | 0 | 1 | string | |||||
| C.16.14 - Patient | On whom or on what the procedure was performed. This is usually an individual human, but can also be performed on animals, groups of humans or animals, organizations or practitioners (for licensing), locations or devices (for safety inspections or regulatory authorizations). If the actual focus of the procedure is different from the subject, the focus element specifies the actual focus of the procedure. | 1 | 1 | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSLocation|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSDevice|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSOrganization|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSGroup) |
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