Procedure resource group

A Procedure resource records one action performed on or for the patient. That covers surgery, but also counseling, education, physiotherapy, and diagnostic procedures. The endpoint codes each procedure with SNOMED CT. The resource follows the FHIR R4 Procedure specification, and each field name below links to its R4 definition.

What becomes a Procedure

Note says	Procedure `code`	`category`
”Laparoscopic appendectomy in March 2025”	`6025007` Laparoscopic appendectomy	Surgical procedure
”Counseled on smoking cessation”	`225323000` Smoking cessation education	Education
”Chest X-ray taken”	`399208008` Plain chest X-ray	Imaging
”Planned colonoscopy, not done because of poor bowel prep”	`73761001` Colonoscopy, with `status: not-done`

The results of a procedure go into an Observation. “Chest X-ray shows right lower lobe consolidation” gives one Procedure for the X-ray, and one imaging Observation for the consolidation.

Procedures not done

The code names the procedure in positive form. A procedure that did not happen keeps its own code and gets a status instead:

Note says	`code`	`status`
”Colonoscopy performed”	`73761001` Colonoscopy	`completed`
”Colonoscopy not done because of poor bowel prep”	`73761001` Colonoscopy	`not-done`
”Colonoscopy scheduled for next week”	`73761001` Colonoscopy	`preparation`

Check status before you treat a Procedure as performed.

Fields

Field	Type	What it holds	Example from a note
`code`	CodeableConcept	The procedure, in SNOMED CT	”appendectomy” → `80146002` Appendectomy
`status`	code	`completed` by default. Also `preparation`, `in-progress`, `not-done`, `on-hold`, `stopped`, `entered-in-error`, or `unknown`. See the R4 value set.	”scheduled for next week” → `preparation`
`category`	CodeableConcept	One of nine SNOMED CT categories: Psychiatry procedure or service, Counselling, Education, Surgical procedure, Laboratory procedure, Imaging, Measurement procedure, Chiropractic manipulation, or Social service procedure. See the R4 value set.
`bodySite`	CodeableConcept list	The body structure, in SNOMED CT	”right hip replacement” → right hip joint structure
`performedDateTime` or `performedString`	dateTime or string	When it was done. A date only when the note states one.	”on 2025-03-14” → `performedDateTime: "2025-03-14"`. “in March 2025” → `performedString: "March 2025"`
`reasonCode`	CodeableConcept list	Why, as text	”for suspected appendicitis”
`outcome`	CodeableConcept	The result, as text	”uncomplicated”
`complication`	CodeableConcept list	Complications, as text	”post-operative wound infection”
`performer`	list of `{ function, actor }`	Who did it, as text. R4 requires `actor`: when the note names a role but no person, `actor` is marked unknown with the data-absent-reason extension.	”by Dr. Lee” → `actor.display: "Dr. Lee"`
`partOf`	Reference list	A larger procedure this one belongs to, as `display` text
`note`	list of Annotation	Extra context
`subject`	Reference	The Patient of the Bundle
`encounter`	Reference	The Encounter of the note
`extension`	list of Extension	Mentions and alternatives

Codes the endpoint can assign

The endpoint only searches a fixed part of each coding system for each field. A code outside that part never appears, and a filter can only narrow the part further, never widen it. Codes come from a fixed scope explains why.

Field	Coding system	Allowed codes	Example
`code`	SNOMED CT	Semantic tag `procedure`	`80146002` Appendectomy
`bodySite`	SNOMED CT	`442083009` Anatomical or acquired body structure, and its descendants	`66754008` Appendix structure
`category`	SNOMED CT	A fixed list of nine: `24642003` Psychiatry procedure or service, `409063005` Counselling, `409073007` Education, `387713003` Surgical procedure, `108252007` Laboratory procedure, `363679005` Imaging, `122869004` Measurement procedure, `46947000` Chiropractic manipulation, `410606002` Social service procedure

Codes with the semantic tag regime/therapy, such as many medication regimens, are outside the allowed set. reasonCode, outcome, and complication hold text, so the endpoint assigns no codes there.

Example

Laparoscopic appendectomy in March 2025 for acute appendicitis. Uncomplicated recovery.

Simplified
JSON

Field	Value
`code`	`6025007` Laparoscopic appendectomy
`status`	`completed`
`category`	`387713003` Surgical procedure
`performedString`	`March 2025`
`reasonCode`	”acute appendicitis”
`outcome`	”Uncomplicated recovery”

{
  "resourceType": "Procedure",
  "id": "a2e6c4f1-9b37-5d08-8c5e-4f1b7a3d9e26",
  "status": "completed",
  "category": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "387713003",
        "display": "Surgical procedure"
      }
    ],
    "text": "Surgical procedure"
  },
  "code": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "6025007",
        "display": "Laparoscopic appendectomy"
      }
    ],
    "text": "Laparoscopic appendectomy"
  },
  "subject": { "reference": "urn:uuid:b49ecda5-92db-5325-a7a9-f82c71500bad", "type": "Patient" },
  "encounter": {
    "reference": "urn:uuid:29543af8-9ec2-528e-8a3b-1e891822d99d",
    "type": "Encounter",
    "identifier": {
      "system": "http://corti.app/fhir/identifier/encounter",
      "value": "enc-88213"
    }
  },
  "performedString": "March 2025",
  "reasonCode": [{ "text": "acute appendicitis" }],
  "outcome": { "text": "Uncomplicated recovery" }
}

The same note also produces a Condition for “acute appendicitis”. The Procedure’s reasonCode holds the reason as text only.

Clinical Text Generation

Medical Coding

FHIR Extraction

Clinical Assistant

What becomes a Procedure

Procedures not done

Fields

Codes the endpoint can assign

Example

Next steps

AllergyIntolerance resource group

Filter FHIR resources

​What becomes a Procedure

​Procedures not done

​Fields

​Codes the endpoint can assign

​Example

​Next steps

AllergyIntolerance resource group

Filter FHIR resources

What becomes a Procedure

Procedures not done

Fields

Codes the endpoint can assign

Example

Next steps