EHDS refined base model for an action that is or was performed on or for a patient

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Code identifying the procedure

SNOMED CT

Date and time of the procedure or interval of its performance

An actor who performed the procedure

Procedure target body site. Details of where the procedure was performed. Laterality may be included as qualifier of the body site.

The reason why the procedure was performed. This may be a concept from a terminology or a reference to a specific instance that describes the reason.

SNOMED CT, ICD-10, Orphacode if rare disease is diagnosed

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

SNOMED CT

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.

ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed

Device used to perform the procedure

Device(s) 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.

Additional information about the procedure

EHDS refined base model for an action that is or was performed on or for a patient

Code identifying the procedure

SNOMED CT

Date and time of the procedure or interval of its performance

An actor who performed the procedure

Procedure target body site. Details of where the procedure was performed. Laterality may be included as qualifier of the body site.

The reason why the procedure was performed. This may be a concept from a terminology or a reference to a specific instance that describes the reason.

SNOMED CT, ICD-10, Orphacode if rare disease is diagnosed

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

SNOMED CT

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.

ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed

Device used to perform the procedure

Device(s) 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.

Additional information about the procedure

EHDS refined base model for an action that is or was performed on or for a patient

Common header for all patient-related data

Patient/subject information

Business identifier for the object

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Code identifying the procedure

SNOMED CT

Date and time of the procedure or interval of its performance

An actor who performed the procedure

Procedure target body site. Details of where the procedure was performed. Laterality may be included as qualifier of the body site.

The reason why the procedure was performed. This may be a concept from a terminology or a reference to a specific instance that describes the reason.

SNOMED CT, ICD-10, Orphacode if rare disease is diagnosed

The outcome of the procedure - did it resolve the reasons for the procedure being performed?

SNOMED CT

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.

ICD-10, SNOMED CT, Orphacode if rare disease is diagnosed

Device used to perform the procedure

Device(s) 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.

Additional information about the procedure