Procedure — Performed action
Any action carried out on or for a patient: surgery, endoscopy, sonography, physiotherapy, counselling. Procedure is the past tense: what was done.
Purpose
Procedure documents an action: invasive (surgery, biopsy) or not (counselling,
therapeutic education, physiotherapy). The distinction with
ServiceRequest
is temporal: ServiceRequest = order (future), Procedure = performed
(past). Procedure can reference the ServiceRequest that ordered it via
basedOn.
Key fields
| Field | Type | Cardinality | Role |
|---|---|---|---|
status | code | 1..1 | Mandatory. preparation, in-progress, not-done, on-hold, stopped, completed, entered-in-error, unknown. |
statusReason | CodeableConcept | 0..1 | Status reason (often for not-done). |
category | CodeableConcept[] | 0..* | Family (surgery, diagnostic, counselling…). |
code | CodeableConcept | 0..1 | Specific act (SNOMED CT, CPT, CCAM, OPCS). |
subject | Reference(Patient | Group) | 1..1 | Mandatory. Beneficiary. |
focus | Reference(Patient | Group | RelatedPerson | Practitioner | Organization | CareTeam | PractitionerRole | Specimen) | 0..1 | Target if different from subject. |
encounter | Reference(Encounter) | 0..1 | Context. |
occurrence[x] | dateTime | Period | string | Age | Range | Timing | 0..1 | When the act took place. |
recorded | dateTime | 0..1 | EHR entry date. |
recorder | Reference(...) | 0..1 | Recorder. |
reportedBoolean | boolean | 0..1 | true if reported (vs primary source). |
performer | BackboneElement[] | 0..* | Performers: actor + function. |
location | Reference(Location) | 0..1 | Where the act was performed. |
reason | CodeableReference[] | 0..* | Medical indication. |
bodySite | CodeableConcept[] | 0..* | Anatomical sites targeted. |
outcome | CodeableConcept | 0..1 | Global result (success, failure, partial). |
complication | CodeableReference[] | 0..* | Complications. |
followUp | CodeableConcept[] | 0..* | Follow-up plan. |
used | CodeableReference[] | 0..* | Devices/materials used. |
Common codings
- SNOMED CT — Procedure hierarchy (387713003). Universal.
- CPT (US) — medical act billing.
- CCAM (FR) — Classification Commune des Actes Médicaux.
- OPCS (UK) — Office of Population Censuses and Surveys.
- ICD-9-CM Vol. 3 (US, legacy, still in billing).
JSON example
14 May 2026 appendectomy, dual-coded SNOMED CT and CPT:
{
"resourceType": "Procedure",
"id": "appendectomy-001",
"status": "completed",
"category": {
"coding": [{
"system": "http://snomed.info/sct",
"code": "387713003",
"display": "Surgical procedure"
}]
},
"code": {
"coding": [{
"system": "http://snomed.info/sct",
"code": "80146002",
"display": "Appendectomy"
}, {
"system": "http://www.ama-assn.org/go/cpt",
"code": "44950"
}]
},
"subject": { "reference": "Patient/doe-john" },
"encounter": { "reference": "Encounter/enc-postop-001" },
"occurrencePeriod": {
"start": "2026-05-14T08:30:00+02:00",
"end": "2026-05-14T10:15:00+02:00"
},
"recorded": "2026-05-14T11:00:00+02:00",
"performer": [{
"function": {
"coding": [{
"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
"code": "PRF",
"display": "performer"
}]
},
"actor": { "reference": "Practitioner/dr-smith" }
}],
"location": { "reference": "Location/or-3" },
"reason": [{
"concept": {
"coding": [{
"system": "http://snomed.info/sct",
"code": "74400008",
"display": "Appendicitis"
}]
}
}],
"bodySite": [{
"coding": [{
"system": "http://snomed.info/sct",
"code": "66754008",
"display": "Appendix structure"
}]
}],
"outcome": {
"coding": [{
"system": "http://snomed.info/sct",
"code": "385669000",
"display": "Successful"
}]
}
}Common pitfalls
- Procedure for an action not yet performed — use ServiceRequest. Procedure assumes the act is at least in progress.
- Missing
code— without a code the resource is useless for statistics or billing. - Missing CPT in the US — Procedure without a CPT code blocks the 837 (X12 healthcare claim).
- Forgotten
bodySitefor surgery — surgery without a site = impossible audit (laterality, organ). - Complications confused with
outcome— outcome = global result, complication = specific adverse event.
Related resources
- ServiceRequest — the order performed.
- Condition — diagnosis indicating the procedure.
- Encounter — hospital context.
- BodyStructure — detailed anatomical site.
- Specimen — collected sample.