Procedure

The Procedure element represents a clinical procedure performed on a subject. For example a surgical or diagnostic procedure such as a biopsy.

By preference a single code to indicate both the procedure and the body site should be used. In cases where this is not possible, the body site should be indicated using a separate ontology class.

Data model

Field	Type	Multiplicity	Description
code	OntologyClass	1..1	clinical procedure performed. REQUIRED.
body_site	OntologyClass	0..1	specific body site where the procedure was performed
performed	TimeElement	0..1	age/time when the procedure was performed

Example

In this example, a skin biopsy from the skin of the forearm is perfomed on an individual who is 25 years old.

procedure:
    code:
        id: "NCIT:C28743"
        label: "Punch Biopsy"
    bodySite:
        id: "UBERON:0003403"
        label: "skin of forearm"
    performed:
        age:
            iso8601duration: "P25Y"

In this case, the code for “Punch biopsy” is not specific to a location, so providing bodySite gives additional useful information.

Explanations

code

This element is an OntologyClass that represents clinical procedure performed on a subject. For instance, Biopsy of Soft Palate would be represented as follows.

{
    "code": {
        "id": "NCIT:C51585",
        "label": "Biopsy of Soft Palate"
    }
}

body site

In cases where it is not possible to represent the procedure adequately with a single OntologyClass, the body site should be indicated using a separate ontology class. For instance, the following indicates a punch biopsy on the skin of the forearm.

{
    "code" {
        "id": "NCIT:C28743",
        "label": "Punch Biopsy"
    },
    "bodySite" {
        "id": "UBERON:0003403",
        "label": "skin of forearm"
    }
}