bodySite"Anatomical site where procedure is performed." For example, "Skin biopsy of the left eyelid." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
complicationAn undesirable event experienced by a patient whilst undergoing a clinical procedure, especially if the event was caused by the procedure itself.
dateTimeThe date (and optionaly the time) that the professional service was performed."Date and time of procedure, may include duration." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
descriptionTextual description of the procedure."Narrative to further describe the procedure." For example, "A 6 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled. Moderate diverticulosis and hemorrhoids were incidentally noted." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
invasivenessOfProcedure"Describes invasiveness of the procedure." For example, Non-Invasive (ex: abdominal sonogram); Minimally Invasive (ex: endoscopy); Invasive (open surgery). - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
performer procedureFacilityPointer to the location (e.g., the Facility) at which the Procedure was performed.
procedureFindings"Records clinically significant observations confirmed or discovered during the procedure or surgery." For example, "Necrotic left ovarian cyst was discovered and removed." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
procedureImplants"Records any materials placed during the procedure including stents, tubes, and drains." For example, "A doohickey pacemaker, number 3975359 was placed." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
procedureListPointer to a list of Procedures (i.e., procedure codes) performed as part of the clinical procedure record."Contains a code indicating a procedure or a non-procedural event involving the patient. This code could come from various coding systems; typically the Common Procedure Terminology (CPT)". - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
relatedProcedure specimensTaken"Records the tissues, objects, or samples taken from the patient during the procedure including biopsies, aspiration fluid, or other samples sent for pathological analysis." For example, "a .01x .02 cm biopsy was taken from the left ventricle." - ONC S&I Clinical Element Data Dictionary (CEDD), March 2012.
statusA value specifying the state of this patient encounter (based on the RIM Act class state machine), for example, active, aborted, completed