# Vercy AI instruction - YAML 1.2 (JSON-compatible) { "vercy": "1.0-draft", "publication": { "status": "published", "adjudicationStatus": "reviewable-draft", "publishableCanonical": false, "generatedAt": "2026-09-06T09:26:28Z", "synthesisSha256": "9e67b5b1cc9b39f288d3f68c18e2c65489efa8822b2a3ac3a826f0217ad29ce8", "providerMode": "single-provider-waiver", "providers": [ "Codex" ], "waivedProviders": [ "Claude", "Grok" ] }, "metaModel": { "id": "WM-ACT-047", "registryId": "vr.wm-act-047", "name": "Medical Procedure", "version": "0.3.0-research.1", "previousVersions": [], "entryKind": "event", "family": "World Models", "category": "Activities and processes", "industry": [ "Cross-industry" ], "domain": [ "ACT.HCR" ], "tags": [ "medical", "procedure", "act.hcr" ], "status": "published" }, "canonicalUrl": "https://ver.cy/models/wm-act-047-medical-procedure/", "sourceUrl": "https://github.com/ver-cy/world-models/tree/feat/mega-model-registry/research/runs/wm-act-047", "model": { "registry_id": "vr.wm-act-047", "model_id": "WM-ACT-047", "name": "Medical Procedure", "entry_kind": "event", "purpose": "Represent one source-qualified medical procedure occurrence or explicit non-performance so agents can distinguish request, preparation, performed technique, status, immediate outcome, outputs and safety links without conflating the event with its plan, subjects or consequences.", "scope_statement": "Owns occurrence identity and lineage, procedure classification, request and plan bindings, status, subject and focus references, performers, occurrence timing and location, method, site, approach, components, used and focal-item references, safety checks, deviations, immediate outcome, output and report links, complication and follow-up links, corrections, provenance, privacy, retention and interoperability. Definitions, requests, plans, appointments, tasks, encounters, consent, people, organizations, locations, devices, substances, specimens, observations, reports, conditions, adverse events, claims, audit and record masters remain external.", "in_scope": [ "Procedure occurrence profile, identity, source, subject, request and authorization bindings, status, participants, timing, location, performed meaning, resources, safety and deviations", "Immediate outcome, output, report, complication, adverse-event and follow-up links, correction, provenance, privacy, retention and version-pinned projections" ], "out_of_scope": [ "Independent reusable procedure definition, ServiceRequest, CarePlan, Appointment, workflow Task, Encounter, Consent, Patient, Practitioner, Organization, Location, Device, Substance, Medication, Specimen, Observation, DiagnosticReport, Condition, AdverseEvent, Claim, Audit or Record lifecycles", "Treating an order as performance, scheduling as start, completion as success, complication as proven causation, reported history as primary evidence or billing code as performed technique", "Providing medical advice, authorizing or controlling real-time procedures, performing clinical actions, deciding malpractice or universally defining professional and legal duties" ], "boundary_notes": [ { "neighbor": "WM-ACT-049 Care Plan / Episode", "distinction": "A care plan may contain intended or performed procedure references, but owns its goals and planning lifecycle. The ledger containment relation is candidate and creates no cascade behavior.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003" ] }, { "neighbor": "WM-ACT-014 Health Care Delivery and WM-ACT-018 Encounter", "distinction": "Care-delivery and Encounter masters own system, visit, service and participant context. The procedure occurrence binds them without absorbing their lifecycle.", "source_refs": [ "SRC-001", "SRC-006", "SRC-012" ] }, { "neighbor": "ServiceRequest, Appointment, Task, Consent and Procedure Definition", "distinction": "These masters own intent, scheduling, workflow fulfillment, authorization and reusable protocol. This event records what was actually attempted or done and the source-qualified links back.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006" ] }, { "neighbor": "WM-ACT-046 Clinical Observation / Diagnosis, DiagnosticReport and Condition", "distinction": "Observations and reports own measured results and interpretations; Condition owns complication or diagnosis assertions. This event owns output links and only a bounded immediate outcome statement.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005" ] }, { "neighbor": "Adverse Event and safety incident", "distinction": "An external adverse-event case owns potential harm, severity, reporting and evolving causality. The procedure occurrence records a typed association without deciding causation.", "source_refs": [ "SRC-004", "SRC-010" ] }, { "neighbor": "Device, Medication, Substance, Biologically Derived Product and Specimen", "distinction": "External masters own item identity and lifecycle. The occurrence records role-qualified use, manipulation, implantation, removal and specimen outputs with exact identifiers where available.", "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-013" ] } ] }, "sources": [ { "id": "SRC-001", "title": "FHIR R5 Procedure", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/procedure.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Defines a clinical event summary for an action performed on or for a subject, including request and parent links, event status, subject, focus, occurrence, recorder, reporter, performers, location, reason, body site, outcome, reports, complications, follow-up, focal devices and used items; it is not a real-time procedure-control record." }, { "id": "SRC-002", "title": "FHIR R5 ServiceRequest", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/servicerequest.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 4 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Separates proposal, plan or order for a service from the Procedure or DiagnosticReport that records performance and results." }, { "id": "SRC-003", "title": "FHIR R5 CarePlan", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/careplan.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Defines patient-specific care intent that may group request resources and performed activities while remaining distinct from generic protocols and the procedure occurrence." }, { "id": "SRC-004", "title": "FHIR R5 AdverseEvent", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/adverseevent.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, maturity level 2 and Trial Use", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Defines harmful, potential or avoided adverse events with uncertain causal relationships, severity, outcome and context, preserving a boundary from the procedure occurrence and from complications asserted as conditions." }, { "id": "SRC-005", "title": "FHIR R5 Observation", "organization": "Health Level Seven International", "url": "https://hl7.org/fhir/R5/observation.html", "version_or_date": "FHIR 5.0.0, 26 March 2023, Normative resource", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Separates measured or assessed results and derived observations from the procedure that generated them and from the diagnostic report that groups them." }, { "id": "SRC-006", "title": "openEHR Reference Model EHR Information Model", "organization": "openEHR Foundation", "url": "https://specifications.openehr.org/releases/RM/Release-1.1.0/ehr.html", "version_or_date": "Reference Model 1.1.0, stable", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Separates INSTRUCTION and ACTIVITY specifications from ACTION records of what was performed, supports ad hoc actions, performer context, timing and a standard instruction state machine across organizations." }, { "id": "SRC-007", "title": "SNOMED CT Concept Model", "organization": "SNOMED International", "url": "https://docs.snomed.org/snomed-ct-practical-guides/snomed-ct-starter-guide/6-snomed-ct-concept-model", "version_or_date": "Living official guide accessed 6 September 2026", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Defines procedure concepts and attributes for site, morphology, method, device, access, direct substance, occurrence, priority, focus, intent, recipient, approach and used substance or energy." }, { "id": "SRC-008", "title": "SNOMED CT Procedure Modeling", "organization": "SNOMED International", "url": "https://docs.snomed.org/snomed-ct-specifications/snomed-ct-editorial-guide/readme/authoring/domain-specific-modeling/procedure/index-2", "version_or_date": "Living Editorial Guide accessed 6 September 2026", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Defines procedure direct and indirect object attributes, combined-procedure criteria and the distinction among procedure, observable entity and evaluation procedure." }, { "id": "SRC-009", "title": "International Classification of Health Interventions Reference Guide", "organization": "World Health Organization", "url": "https://icd.who.int/dev11/Downloads/Download?fileName=ichi/ICHI_Reference_Guide.pdf", "version_or_date": "ICHI Reference Guide, current development publication accessed 6 September 2026", "source_type": "classifier", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Classifies intervention target, action and means; explains multiple actions, routine components, residual categories and extension codes while distinguishing planning from preparation." }, { "id": "SRC-010", "title": "WHO Surgical Safety Checklist tools and resources", "organization": "World Health Organization", "url": "https://www.who.int/teams/integrated-health-services/quality-of-care-and-patient-safety/patient-safety-guidance-and-tools/safe-surgery/tool-and-resources", "version_or_date": "WHO checklist and implementation material, 2009 with current resource page accessed 6 September 2026", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Supports identity, site, procedure and consent confirmation, team participation, pre-anesthesia, pre-incision and before-leaving checkpoints, and local adaptation under governance." }, { "id": "SRC-011", "title": "Universal Protocol: Pre-procedure Verification", "organization": "Joint Commission", "url": "https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000001458", "version_or_date": "Official standards FAQ accessed 6 September 2026", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "United States accreditation profile for complementary wrong-person, wrong-site and wrong-procedure prevention, patient involvement and a final team time-out immediately before incision." }, { "id": "SRC-012", "title": "OMOP Common Data Model v5.4", "organization": "Observational Health Data Sciences and Informatics", "url": "https://ohdsi.github.io/CommonDataModel/cdm54.html", "version_or_date": "OMOP CDM 5.4", "source_type": "schema", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Defines Procedure Occurrence identity, subject, provider, visit, start and end times, source values, normalized concepts and modifiers; warns that orders and performed activities may coexist and source-to-standard transformation requires explicit ETL choices." }, { "id": "SRC-013", "title": "UDI Basics", "organization": "United States Food and Drug Administration", "url": "https://www.fda.gov/medical-devices/unique-device-identification-system-udi-system/udi-basics", "version_or_date": "Official page accessed 6 September 2026", "source_type": "public-authority", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "United States profile for device identifier, production identifier, lot, serial and expiry needed to distinguish device model identity from the specific item used, implanted, removed or manipulated." }, { "id": "SRC-014", "title": "Regulation (EU) 2016/679 General Data Protection Regulation", "organization": "European Union", "url": "https://eur-lex.europa.eu/eli/reg/2016/679/oj", "version_or_date": "27 April 2016, applicable from 25 May 2018", "source_type": "legislation", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Provides purpose limitation, minimization, accuracy, security, access and correction safeguards for health and related procedure data." }, { "id": "SRC-015", "title": "PROV-O: The PROV Ontology", "organization": "World Wide Web Consortium", "url": "https://www.w3.org/TR/prov-o/", "version_or_date": "W3C Recommendation, 30 April 2013", "source_type": "ontology", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Provides activity, entity, agent, attribution, delegation, derivation, revision, invalidation and generation semantics for procedure records and linked evidence." }, { "id": "SRC-016", "title": "Date and Time on the Internet: Timestamps", "organization": "Internet Engineering Task Force", "url": "https://www.rfc-editor.org/info/rfc3339/", "version_or_date": "RFC 3339, July 2002", "source_type": "standard", "primary_source": true, "authority_tier": 1, "accessed_at": "2026-09-06T09:22:00Z", "relevance": "Provides interoperable timestamps with seconds and explicit UTC relationship for scheduled, occurrence, performer, recorded, reported, ingested and knowledge times." } ], "structure": { "bundles": [ { "id": "procedure-occurrence-identity-boundary-and-authority", "name": "Procedure occurrence identity, boundary and authority", "description": "Groups governed procedure-occurrence context for procedure occurrence identity, boundary and authority.", "rationale": "A stable occurrence root represents what was attempted or performed and binds, but does not replace, the request, plan, consent, encounter and care-delivery context.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-015" ], "layers": [ { "id": "occurrence-profile-identity-source-and-lineage", "name": "Occurrence profile, identity, source and lineage", "description": "Groups source-qualified procedure context for occurrence profile, identity, source and lineage.", "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ], "findings": [ { "id": "procedure-occurrence-profile-kind-scope-specialty-and-event-boundary", "name": "Procedure occurrence profile, kind, scope, specialty and event boundary", "description": "Records procedure occurrence profile, kind, scope, specialty and event boundary as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ], "questions": [ { "id": "procedure-occurrence-profile-kind-scope-specialty-and-event-boundary-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish procedure occurrence profile, kind, scope, specialty and event boundary?", "kind": "classification", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "procedure-occurrence-profile-kind-scope-specialty-and-event-boundary-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported procedure occurrence profile, kind, scope, specialty and event boundary, using which evidence, competence and delegated authority?", "kind": "process", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "procedure-occurrence-profile-kind-scope-specialty-and-event-boundary-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to procedure occurrence profile, kind, scope, specialty and event boundary, and how may it be validated, challenged, corrected or retained?", "kind": "provenance", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "procedure-occurrence-profile-kind-scope-specialty-and-event-boundary-data", "name": "Procedure occurrence profile, kind, scope, specialty and event boundary data", "description": "Typed procedure-occurrence data for procedure occurrence profile, kind, scope, specialty and event boundary with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ] } ], "artifacts": [ { "id": "procedure-occurrence-profile-kind-scope-specialty-and-event-boundary-record", "name": "Procedure occurrence profile, kind, scope, specialty and event boundary record", "description": "Immutable or successor-versioned evidence-bearing procedure record for procedure occurrence profile, kind, scope, specialty and event boundary.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus procedure-occurrence-profile-kind-scope-specialty-and-event-boundary assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "occurrence-identifier-source-version-predecessor-successor-and-lineage", "name": "Occurrence identifier, source, version, predecessor, successor and lineage", "description": "Records occurrence identifier, source, version, predecessor, successor and lineage as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ], "questions": [ { "id": "occurrence-identifier-source-version-predecessor-successor-and-lineage-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish occurrence identifier, source, version, predecessor, successor and lineage?", "kind": "identity", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "occurrence-identifier-source-version-predecessor-successor-and-lineage-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported occurrence identifier, source, version, predecessor, successor and lineage, using which evidence, competence and delegated authority?", "kind": "temporal", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "occurrence-identifier-source-version-predecessor-successor-and-lineage-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to occurrence identifier, source, version, predecessor, successor and lineage, and how may it be validated, challenged, corrected or retained?", "kind": "privacy", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "occurrence-identifier-source-version-predecessor-successor-and-lineage-data", "name": "Occurrence identifier, source, version, predecessor, successor and lineage data", "description": "Typed procedure-occurrence data for occurrence identifier, source, version, predecessor, successor and lineage with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ] } ], "artifacts": [ { "id": "occurrence-identifier-source-version-predecessor-successor-and-lineage-record", "name": "Occurrence identifier, source, version, predecessor, successor and lineage record", "description": "Immutable or successor-versioned evidence-bearing procedure record for occurrence identifier, source, version, predecessor, successor and lineage.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus occurrence-identifier-source-version-predecessor-successor-and-lineage assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "request-plan-consent-indication-and-authorization", "name": "Request, plan, consent, indication and authorization", "description": "Groups source-qualified procedure context for request, plan, consent, indication and authorization.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ], "findings": [ { "id": "service-request-care-plan-appointment-task-protocol-and-priority-binding", "name": "Service request, care plan, appointment, task, protocol and priority binding", "description": "Records service request, care plan, appointment, task, protocol and priority binding as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ], "questions": [ { "id": "service-request-care-plan-appointment-task-protocol-and-priority-binding-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish service request, care plan, appointment, task, protocol and priority binding?", "kind": "relationship", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "service-request-care-plan-appointment-task-protocol-and-priority-binding-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported service request, care plan, appointment, task, protocol and priority binding, using which evidence, competence and delegated authority?", "kind": "event", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "service-request-care-plan-appointment-task-protocol-and-priority-binding-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to service request, care plan, appointment, task, protocol and priority binding, and how may it be validated, challenged, corrected or retained?", "kind": "retention", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "service-request-care-plan-appointment-task-protocol-and-priority-binding-data", "name": "Service request, care plan, appointment, task, protocol and priority binding data", "description": "Typed procedure-occurrence data for service request, care plan, appointment, task, protocol and priority binding with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ] } ], "artifacts": [ { "id": "service-request-care-plan-appointment-task-protocol-and-priority-binding-record", "name": "Service request, care plan, appointment, task, protocol and priority binding record", "description": "Immutable or successor-versioned evidence-bearing procedure record for service request, care plan, appointment, task, protocol and priority binding.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus service-request-care-plan-appointment-task-protocol-and-priority-binding assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ] } ], "inline_only_rationale": null }, { "id": "indication-goal-consent-capacity-authorization-urgency-and-decision-basis", "name": "Indication, goal, consent, capacity, authorization, urgency and decision basis", "description": "Records indication, goal, consent, capacity, authorization, urgency and decision basis as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ], "questions": [ { "id": "indication-goal-consent-capacity-authorization-urgency-and-decision-basis-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish indication, goal, consent, capacity, authorization, urgency and decision basis?", "kind": "authority", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "indication-goal-consent-capacity-authorization-urgency-and-decision-basis-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported indication, goal, consent, capacity, authorization, urgency and decision basis, using which evidence, competence and delegated authority?", "kind": "measurement", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "indication-goal-consent-capacity-authorization-urgency-and-decision-basis-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to indication, goal, consent, capacity, authorization, urgency and decision basis, and how may it be validated, challenged, corrected or retained?", "kind": "interoperability", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "indication-goal-consent-capacity-authorization-urgency-and-decision-basis-data", "name": "Indication, goal, consent, capacity, authorization, urgency and decision basis data", "description": "Typed procedure-occurrence data for indication, goal, consent, capacity, authorization, urgency and decision basis with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ] } ], "artifacts": [ { "id": "indication-goal-consent-capacity-authorization-urgency-and-decision-basis-record", "name": "Indication, goal, consent, capacity, authorization, urgency and decision basis record", "description": "Immutable or successor-versioned evidence-bearing procedure record for indication, goal, consent, capacity, authorization, urgency and decision basis.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus indication-goal-consent-capacity-authorization-urgency-and-decision-basis assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-010", "SRC-011" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "procedure-definition-components-participants-and-resources", "name": "Procedure definition, components, participants and resources", "description": "Groups governed procedure-occurrence context for procedure definition, components, participants and resources.", "rationale": "The performed meaning combines code, method, target, technique, component and participant roles while preserving external people, device and material masters.", "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013" ], "layers": [ { "id": "code-method-site-approach-focus-and-intent", "name": "Code, method, site, approach, focus and intent", "description": "Groups source-qualified procedure context for code, method, site, approach, focus and intent.", "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ], "findings": [ { "id": "procedure-code-category-intent-target-action-means-and-recipient", "name": "Procedure code, category, intent, target, action, means and recipient", "description": "Records procedure code, category, intent, target, action, means and recipient as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ], "questions": [ { "id": "procedure-code-category-intent-target-action-means-and-recipient-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish procedure code, category, intent, target, action, means and recipient?", "kind": "definition", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "procedure-code-category-intent-target-action-means-and-recipient-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported procedure code, category, intent, target, action, means and recipient, using which evidence, competence and delegated authority?", "kind": "evidence", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "procedure-code-category-intent-target-action-means-and-recipient-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to procedure code, category, intent, target, action, means and recipient, and how may it be validated, challenged, corrected or retained?", "kind": "quality", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "procedure-code-category-intent-target-action-means-and-recipient-data", "name": "Procedure code, category, intent, target, action, means and recipient data", "description": "Typed procedure-occurrence data for procedure code, category, intent, target, action, means and recipient with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ] } ], "artifacts": [ { "id": "procedure-code-category-intent-target-action-means-and-recipient-record", "name": "Procedure code, category, intent, target, action, means and recipient record", "description": "Immutable or successor-versioned evidence-bearing procedure record for procedure code, category, intent, target, action, means and recipient.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus procedure-code-category-intent-target-action-means-and-recipient assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ] } ], "inline_only_rationale": null }, { "id": "method-technique-approach-access-body-site-morphology-focus-and-laterality", "name": "Method, technique, approach, access, body site, morphology, focus and laterality", "description": "Records method, technique, approach, access, body site, morphology, focus and laterality as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ], "questions": [ { "id": "method-technique-approach-access-body-site-morphology-focus-and-laterality-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish method, technique, approach, access, body site, morphology, focus and laterality?", "kind": "composition", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "method-technique-approach-access-body-site-morphology-focus-and-laterality-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported method, technique, approach, access, body site, morphology, focus and laterality, using which evidence, competence and delegated authority?", "kind": "state", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "method-technique-approach-access-body-site-morphology-focus-and-laterality-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to method, technique, approach, access, body site, morphology, focus and laterality, and how may it be validated, challenged, corrected or retained?", "kind": "security", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "method-technique-approach-access-body-site-morphology-focus-and-laterality-data", "name": "Method, technique, approach, access, body site, morphology, focus and laterality data", "description": "Typed procedure-occurrence data for method, technique, approach, access, body site, morphology, focus and laterality with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ] } ], "artifacts": [ { "id": "method-technique-approach-access-body-site-morphology-focus-and-laterality-record", "name": "Method, technique, approach, access, body site, morphology, focus and laterality record", "description": "Immutable or successor-versioned evidence-bearing procedure record for method, technique, approach, access, body site, morphology, focus and laterality.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus method-technique-approach-access-body-site-morphology-focus-and-laterality assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009", "SRC-012" ] } ], "inline_only_rationale": null } ] }, { "id": "performers-devices-substances-specimens-and-components", "name": "Performers, devices, substances, specimens and components", "description": "Groups source-qualified procedure context for performers, devices, substances, specimens and components.", "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ], "findings": [ { "id": "performer-assistant-anesthesia-device-care-team-organization-and-role-period", "name": "Performer, assistant, anesthesia, device, care team, organization and role period", "description": "Records performer, assistant, anesthesia, device, care team, organization and role period as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ], "questions": [ { "id": "performer-assistant-anesthesia-device-care-team-organization-and-role-period-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish performer, assistant, anesthesia, device, care team, organization and role period?", "kind": "ownership", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "performer-assistant-anesthesia-device-care-team-organization-and-role-period-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported performer, assistant, anesthesia, device, care team, organization and role period, using which evidence, competence and delegated authority?", "kind": "exception", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "performer-assistant-anesthesia-device-care-team-organization-and-role-period-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to performer, assistant, anesthesia, device, care team, organization and role period, and how may it be validated, challenged, corrected or retained?", "kind": "decision", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "performer-assistant-anesthesia-device-care-team-organization-and-role-period-data", "name": "Performer, assistant, anesthesia, device, care team, organization and role period data", "description": "Typed procedure-occurrence data for performer, assistant, anesthesia, device, care team, organization and role period with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ] } ], "artifacts": [ { "id": "performer-assistant-anesthesia-device-care-team-organization-and-role-period-record", "name": "Performer, assistant, anesthesia, device, care team, organization and role period record", "description": "Immutable or successor-versioned evidence-bearing procedure record for performer, assistant, anesthesia, device, care team, organization and role period.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus performer-assistant-anesthesia-device-care-team-organization-and-role-period assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ] } ], "inline_only_rationale": null }, { "id": "used-device-focal-device-implant-explant-substance-medication-specimen-and-lot", "name": "Used device, focal device, implant, explant, substance, medication, specimen and lot", "description": "Records used device, focal device, implant, explant, substance, medication, specimen and lot as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ], "questions": [ { "id": "used-device-focal-device-implant-explant-substance-medication-specimen-and-lot-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish used device, focal device, implant, explant, substance, medication, specimen and lot?", "kind": "relationship", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "used-device-focal-device-implant-explant-substance-medication-specimen-and-lot-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported used device, focal device, implant, explant, substance, medication, specimen and lot, using which evidence, competence and delegated authority?", "kind": "provenance", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "used-device-focal-device-implant-explant-substance-medication-specimen-and-lot-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to used device, focal device, implant, explant, substance, medication, specimen and lot, and how may it be validated, challenged, corrected or retained?", "kind": "lifecycle", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "used-device-focal-device-implant-explant-substance-medication-specimen-and-lot-data", "name": "Used device, focal device, implant, explant, substance, medication, specimen and lot data", "description": "Typed procedure-occurrence data for used device, focal device, implant, explant, substance, medication, specimen and lot with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ] } ], "artifacts": [ { "id": "used-device-focal-device-implant-explant-substance-medication-specimen-and-lot-record", "name": "Used device, focal device, implant, explant, substance, medication, specimen and lot record", "description": "Immutable or successor-versioned evidence-bearing procedure record for used device, focal device, implant, explant, substance, medication, specimen and lot.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus used-device-focal-device-implant-explant-substance-medication-specimen-and-lot assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-013" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "preparation-verification-performance-and-deviation", "name": "Preparation, verification, performance and deviation", "description": "Groups governed procedure-occurrence context for preparation, verification, performance and deviation.", "rationale": "Readiness and safety assertions precede an attributable performance record, and actual technique or scope may differ from the plan.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-014", "SRC-016" ], "layers": [ { "id": "readiness-patient-site-procedure-and-team-verification", "name": "Readiness, patient, site, procedure and team verification", "description": "Groups source-qualified procedure context for readiness, patient, site, procedure and team verification.", "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ], "findings": [ { "id": "subject-identity-procedure-site-consent-equipment-and-document-verification", "name": "Subject identity, procedure, site, consent, equipment and document verification", "description": "Records subject identity, procedure, site, consent, equipment and document verification as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ], "questions": [ { "id": "subject-identity-procedure-site-consent-equipment-and-document-verification-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish subject identity, procedure, site, consent, equipment and document verification?", "kind": "validation", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "subject-identity-procedure-site-consent-equipment-and-document-verification-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported subject identity, procedure, site, consent, equipment and document verification, using which evidence, competence and delegated authority?", "kind": "privacy", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "subject-identity-procedure-site-consent-equipment-and-document-verification-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to subject identity, procedure, site, consent, equipment and document verification, and how may it be validated, challenged, corrected or retained?", "kind": "identity", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "subject-identity-procedure-site-consent-equipment-and-document-verification-data", "name": "Subject identity, procedure, site, consent, equipment and document verification data", "description": "Typed procedure-occurrence data for subject identity, procedure, site, consent, equipment and document verification with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ] } ], "artifacts": [ { "id": "subject-identity-procedure-site-consent-equipment-and-document-verification-record", "name": "Subject identity, procedure, site, consent, equipment and document verification record", "description": "Immutable or successor-versioned evidence-bearing procedure record for subject identity, procedure, site, consent, equipment and document verification.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus subject-identity-procedure-site-consent-equipment-and-document-verification assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ] } ], "inline_only_rationale": null }, { "id": "team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check", "name": "Team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check", "description": "Records team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ], "questions": [ { "id": "team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check?", "kind": "process", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check, using which evidence, competence and delegated authority?", "kind": "retention", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check, and how may it be validated, challenged, corrected or retained?", "kind": "classification", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check-data", "name": "Team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check data", "description": "Typed procedure-occurrence data for team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ] } ], "artifacts": [ { "id": "team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check-record", "name": "Team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check record", "description": "Immutable or successor-versioned evidence-bearing procedure record for team briefing, time-out, anesthesia, allergy, infection, bleeding and readiness check.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus team-briefing-time-out-anesthesia-allergy-infection-bleeding-and-readiness-check assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-002", "SRC-006", "SRC-010", "SRC-011", "SRC-014" ] } ], "inline_only_rationale": null } ] }, { "id": "occurrence-time-location-steps-components-and-deviations", "name": "Occurrence time, location, steps, components and deviations", "description": "Groups source-qualified procedure context for occurrence time, location, steps, components and deviations.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ], "findings": [ { "id": "occurrence-start-end-duration-location-encounter-performer-period-and-setting", "name": "Occurrence start, end, duration, location, encounter, performer period and setting", "description": "Records occurrence start, end, duration, location, encounter, performer period and setting as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ], "questions": [ { "id": "occurrence-start-end-duration-location-encounter-performer-period-and-setting-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish occurrence start, end, duration, location, encounter, performer period and setting?", "kind": "temporal", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "occurrence-start-end-duration-location-encounter-performer-period-and-setting-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported occurrence start, end, duration, location, encounter, performer period and setting, using which evidence, competence and delegated authority?", "kind": "interoperability", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "occurrence-start-end-duration-location-encounter-performer-period-and-setting-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to occurrence start, end, duration, location, encounter, performer period and setting, and how may it be validated, challenged, corrected or retained?", "kind": "relationship", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "occurrence-start-end-duration-location-encounter-performer-period-and-setting-data", "name": "Occurrence start, end, duration, location, encounter, performer period and setting data", "description": "Typed procedure-occurrence data for occurrence start, end, duration, location, encounter, performer period and setting with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ] } ], "artifacts": [ { "id": "occurrence-start-end-duration-location-encounter-performer-period-and-setting-record", "name": "Occurrence start, end, duration, location, encounter, performer period and setting record", "description": "Immutable or successor-versioned evidence-bearing procedure record for occurrence start, end, duration, location, encounter, performer period and setting.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus occurrence-start-end-duration-location-encounter-performer-period-and-setting assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "performed-step-component-part-of-sequence-technique-change-and-deviation", "name": "Performed step, component, part-of, sequence, technique change and deviation", "description": "Records performed step, component, part-of, sequence, technique change and deviation as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ], "questions": [ { "id": "performed-step-component-part-of-sequence-technique-change-and-deviation-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish performed step, component, part-of, sequence, technique change and deviation?", "kind": "event", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "performed-step-component-part-of-sequence-technique-change-and-deviation-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported performed step, component, part-of, sequence, technique change and deviation, using which evidence, competence and delegated authority?", "kind": "quality", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "performed-step-component-part-of-sequence-technique-change-and-deviation-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to performed step, component, part-of, sequence, technique change and deviation, and how may it be validated, challenged, corrected or retained?", "kind": "authority", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "performed-step-component-part-of-sequence-technique-change-and-deviation-data", "name": "Performed step, component, part-of, sequence, technique change and deviation data", "description": "Typed procedure-occurrence data for performed step, component, part-of, sequence, technique change and deviation with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ] } ], "artifacts": [ { "id": "performed-step-component-part-of-sequence-technique-change-and-deviation-record", "name": "Performed step, component, part-of, sequence, technique change and deviation record", "description": "Immutable or successor-versioned evidence-bearing procedure record for performed step, component, part-of, sequence, technique change and deviation.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus performed-step-component-part-of-sequence-technique-change-and-deviation assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-016" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "outcome-outputs-reports-complications-and-follow-up", "name": "Outcome, outputs, reports, complications and follow-up", "description": "Groups governed procedure-occurrence context for outcome, outputs, reports, complications and follow-up.", "rationale": "Completion status is separate from success, measured outcomes, generated reports, complications, adverse events and later care.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-010", "SRC-012", "SRC-014", "SRC-015" ], "layers": [ { "id": "immediate-outcome-output-observation-report-and-specimen", "name": "Immediate outcome, output, observation, report and specimen", "description": "Groups source-qualified procedure context for immediate outcome, output, observation, report and specimen.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ], "findings": [ { "id": "completion-result-immediate-outcome-goal-attainment-and-uncertainty", "name": "Completion, result, immediate outcome, goal attainment and uncertainty", "description": "Records completion, result, immediate outcome, goal attainment and uncertainty as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ], "questions": [ { "id": "completion-result-immediate-outcome-goal-attainment-and-uncertainty-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish completion, result, immediate outcome, goal attainment and uncertainty?", "kind": "measurement", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "completion-result-immediate-outcome-goal-attainment-and-uncertainty-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported completion, result, immediate outcome, goal attainment and uncertainty, using which evidence, competence and delegated authority?", "kind": "security", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "completion-result-immediate-outcome-goal-attainment-and-uncertainty-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to completion, result, immediate outcome, goal attainment and uncertainty, and how may it be validated, challenged, corrected or retained?", "kind": "composition", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "completion-result-immediate-outcome-goal-attainment-and-uncertainty-data", "name": "Completion, result, immediate outcome, goal attainment and uncertainty data", "description": "Typed procedure-occurrence data for completion, result, immediate outcome, goal attainment and uncertainty with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ] } ], "artifacts": [ { "id": "completion-result-immediate-outcome-goal-attainment-and-uncertainty-record", "name": "Completion, result, immediate outcome, goal attainment and uncertainty record", "description": "Immutable or successor-versioned evidence-bearing procedure record for completion, result, immediate outcome, goal attainment and uncertainty.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus completion-result-immediate-outcome-goal-attainment-and-uncertainty assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ] } ], "inline_only_rationale": null }, { "id": "observation-diagnostic-report-document-image-specimen-product-and-evidence-output", "name": "Observation, diagnostic report, document, image, specimen, product and evidence output", "description": "Records observation, diagnostic report, document, image, specimen, product and evidence output as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ], "questions": [ { "id": "observation-diagnostic-report-document-image-specimen-product-and-evidence-output-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish observation, diagnostic report, document, image, specimen, product and evidence output?", "kind": "relationship", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "observation-diagnostic-report-document-image-specimen-product-and-evidence-output-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported observation, diagnostic report, document, image, specimen, product and evidence output, using which evidence, competence and delegated authority?", "kind": "decision", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "observation-diagnostic-report-document-image-specimen-product-and-evidence-output-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to observation, diagnostic report, document, image, specimen, product and evidence output, and how may it be validated, challenged, corrected or retained?", "kind": "ownership", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "observation-diagnostic-report-document-image-specimen-product-and-evidence-output-data", "name": "Observation, diagnostic report, document, image, specimen, product and evidence output data", "description": "Typed procedure-occurrence data for observation, diagnostic report, document, image, specimen, product and evidence output with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ] } ], "artifacts": [ { "id": "observation-diagnostic-report-document-image-specimen-product-and-evidence-output-record", "name": "Observation, diagnostic report, document, image, specimen, product and evidence output record", "description": "Immutable or successor-versioned evidence-bearing procedure record for observation, diagnostic report, document, image, specimen, product and evidence output.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus observation-diagnostic-report-document-image-specimen-product-and-evidence-output assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-009", "SRC-012" ] } ], "inline_only_rationale": null } ] }, { "id": "complication-adverse-event-sequela-recovery-and-follow-up", "name": "Complication, adverse event, sequela, recovery and follow-up", "description": "Groups source-qualified procedure context for complication, adverse event, sequela, recovery and follow-up.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ], "findings": [ { "id": "complication-adverse-event-near-miss-severity-causality-and-condition-reference", "name": "Complication, adverse event, near miss, severity, causality and condition reference", "description": "Records complication, adverse event, near miss, severity, causality and condition reference as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ], "questions": [ { "id": "complication-adverse-event-near-miss-severity-causality-and-condition-reference-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish complication, adverse event, near miss, severity, causality and condition reference?", "kind": "evidence", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "complication-adverse-event-near-miss-severity-causality-and-condition-reference-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported complication, adverse event, near miss, severity, causality and condition reference, using which evidence, competence and delegated authority?", "kind": "lifecycle", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "complication-adverse-event-near-miss-severity-causality-and-condition-reference-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to complication, adverse event, near miss, severity, causality and condition reference, and how may it be validated, challenged, corrected or retained?", "kind": "validation", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "complication-adverse-event-near-miss-severity-causality-and-condition-reference-data", "name": "Complication, adverse event, near miss, severity, causality and condition reference data", "description": "Typed procedure-occurrence data for complication, adverse event, near miss, severity, causality and condition reference with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "complication-adverse-event-near-miss-severity-causality-and-condition-reference-record", "name": "Complication, adverse event, near miss, severity, causality and condition reference record", "description": "Immutable or successor-versioned evidence-bearing procedure record for complication, adverse event, near miss, severity, causality and condition reference.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus complication-adverse-event-near-miss-severity-causality-and-condition-reference assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff", "name": "Follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff", "description": "Records follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ], "questions": [ { "id": "follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff?", "kind": "process", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff, using which evidence, competence and delegated authority?", "kind": "identity", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff, and how may it be validated, challenged, corrected or retained?", "kind": "process", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff-data", "name": "Follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff data", "description": "Typed procedure-occurrence data for follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff-record", "name": "Follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff record", "description": "Immutable or successor-versioned evidence-bearing procedure record for follow-up instruction, monitoring, recovery, rehabilitation, escalation and handoff.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus follow-up-instruction-monitoring-recovery-rehabilitation-escalation-and-handoff assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-010", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "status-nonperformance-correction-composition-and-safe-use", "name": "Status, non-performance, correction, composition and safe use", "description": "Groups governed procedure-occurrence context for status, non-performance, correction, composition and safe use.", "rationale": "Event state, cancellation and historical correction remain explicit, while repeated and component procedures keep independent identity and plan containment remains candidate.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-010", "SRC-012", "SRC-015", "SRC-016" ], "layers": [ { "id": "event-status-reason-suspension-stopping-and-nonperformance", "name": "Event status, reason, suspension, stopping and non-performance", "description": "Groups source-qualified procedure context for event status, reason, suspension, stopping and non-performance.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ], "findings": [ { "id": "preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason", "name": "Preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason", "description": "Records preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ], "questions": [ { "id": "preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason?", "kind": "state", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason, using which evidence, competence and delegated authority?", "kind": "classification", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason, and how may it be validated, challenged, corrected or retained?", "kind": "temporal", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason-data", "name": "Preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason data", "description": "Typed procedure-occurrence data for preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ] } ], "artifacts": [ { "id": "preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason-record", "name": "Preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason record", "description": "Immutable or successor-versioned evidence-bearing procedure record for preparation, in-progress, on-hold, stopped, completed, error, unknown and status reason.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus preparation-in-progress-on-hold-stopped-completed-error-unknown-and-status-reason assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned", "name": "Not-done, cancelled, postponed, aborted, refused, contraindicated and replanned", "description": "Records not-done, cancelled, postponed, aborted, refused, contraindicated and replanned as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ], "questions": [ { "id": "not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish not-done, cancelled, postponed, aborted, refused, contraindicated and replanned?", "kind": "exception", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported not-done, cancelled, postponed, aborted, refused, contraindicated and replanned, using which evidence, competence and delegated authority?", "kind": "relationship", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to not-done, cancelled, postponed, aborted, refused, contraindicated and replanned, and how may it be validated, challenged, corrected or retained?", "kind": "event", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned-data", "name": "Not-done, cancelled, postponed, aborted, refused, contraindicated and replanned data", "description": "Typed procedure-occurrence data for not-done, cancelled, postponed, aborted, refused, contraindicated and replanned with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ] } ], "artifacts": [ { "id": "not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned-record", "name": "Not-done, cancelled, postponed, aborted, refused, contraindicated and replanned record", "description": "Immutable or successor-versioned evidence-bearing procedure record for not-done, cancelled, postponed, aborted, refused, contraindicated and replanned.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus not-done-cancelled-postponed-aborted-refused-contraindicated-and-replanned assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-006", "SRC-010", "SRC-016" ] } ], "inline_only_rationale": null } ] }, { "id": "part-of-repeat-revision-reporting-and-correction-lineage", "name": "Part-of, repeat, revision, reporting and correction lineage", "description": "Groups source-qualified procedure context for part-of, repeat, revision, reporting and correction lineage.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ], "findings": [ { "id": "parent-child-combined-routine-component-repeat-revision-and-care-plan-membership", "name": "Parent-child, combined, routine component, repeat, revision and care-plan membership", "description": "Records parent-child, combined, routine component, repeat, revision and care-plan membership as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ], "questions": [ { "id": "parent-child-combined-routine-component-repeat-revision-and-care-plan-membership-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish parent-child, combined, routine component, repeat, revision and care-plan membership?", "kind": "composition", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "parent-child-combined-routine-component-repeat-revision-and-care-plan-membership-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported parent-child, combined, routine component, repeat, revision and care-plan membership, using which evidence, competence and delegated authority?", "kind": "authority", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "parent-child-combined-routine-component-repeat-revision-and-care-plan-membership-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to parent-child, combined, routine component, repeat, revision and care-plan membership, and how may it be validated, challenged, corrected or retained?", "kind": "measurement", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "parent-child-combined-routine-component-repeat-revision-and-care-plan-membership-data", "name": "Parent-child, combined, routine component, repeat, revision and care-plan membership data", "description": "Typed procedure-occurrence data for parent-child, combined, routine component, repeat, revision and care-plan membership with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ] } ], "artifacts": [ { "id": "parent-child-combined-routine-component-repeat-revision-and-care-plan-membership-record", "name": "Parent-child, combined, routine component, repeat, revision and care-plan membership record", "description": "Immutable or successor-versioned evidence-bearing procedure record for parent-child, combined, routine component, repeat, revision and care-plan membership.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus parent-child-combined-routine-component-repeat-revision-and-care-plan-membership assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement", "name": "Primary, reported, duplicate, amended, corrected, entered-in-error and replacement", "description": "Records primary, reported, duplicate, amended, corrected, entered-in-error and replacement as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ], "questions": [ { "id": "primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish primary, reported, duplicate, amended, corrected, entered-in-error and replacement?", "kind": "provenance", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported primary, reported, duplicate, amended, corrected, entered-in-error and replacement, using which evidence, competence and delegated authority?", "kind": "composition", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to primary, reported, duplicate, amended, corrected, entered-in-error and replacement, and how may it be validated, challenged, corrected or retained?", "kind": "evidence", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement-data", "name": "Primary, reported, duplicate, amended, corrected, entered-in-error and replacement data", "description": "Typed procedure-occurrence data for primary, reported, duplicate, amended, corrected, entered-in-error and replacement with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ] } ], "artifacts": [ { "id": "primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement-record", "name": "Primary, reported, duplicate, amended, corrected, entered-in-error and replacement record", "description": "Immutable or successor-versioned evidence-bearing procedure record for primary, reported, duplicate, amended, corrected, entered-in-error and replacement.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus primary-reported-duplicate-amended-corrected-entered-in-error-and-replacement assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-003", "SRC-006", "SRC-008", "SRC-009", "SRC-012", "SRC-015" ] } ], "inline_only_rationale": null } ] } ] }, { "id": "quality-provenance-privacy-retention-interoperability-and-agents", "name": "Quality, provenance, privacy, retention, interoperability and agents", "description": "Groups governed procedure-occurrence context for quality, provenance, privacy, retention, interoperability and agents.", "rationale": "Clinical safety and reuse depend on source fidelity, protected access, append-only history and loss-aware projections rather than the storage format.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-010", "SRC-011", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "layers": [ { "id": "source-quality-safety-access-consent-and-confidentiality", "name": "Source quality, safety, access, consent and confidentiality", "description": "Groups source-qualified procedure context for source quality, safety, access, consent and confidentiality.", "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ], "findings": [ { "id": "source-record-actor-tool-protocol-evidence-quality-safety-and-derivation", "name": "Source record, actor, tool, protocol, evidence, quality, safety and derivation", "description": "Records source record, actor, tool, protocol, evidence, quality, safety and derivation as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ], "questions": [ { "id": "source-record-actor-tool-protocol-evidence-quality-safety-and-derivation-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish source record, actor, tool, protocol, evidence, quality, safety and derivation?", "kind": "provenance", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "source-record-actor-tool-protocol-evidence-quality-safety-and-derivation-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported source record, actor, tool, protocol, evidence, quality, safety and derivation, using which evidence, competence and delegated authority?", "kind": "ownership", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "source-record-actor-tool-protocol-evidence-quality-safety-and-derivation-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to source record, actor, tool, protocol, evidence, quality, safety and derivation, and how may it be validated, challenged, corrected or retained?", "kind": "state", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "source-record-actor-tool-protocol-evidence-quality-safety-and-derivation-data", "name": "Source record, actor, tool, protocol, evidence, quality, safety and derivation data", "description": "Typed procedure-occurrence data for source record, actor, tool, protocol, evidence, quality, safety and derivation with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "1", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "source-record-actor-tool-protocol-evidence-quality-safety-and-derivation-record", "name": "Source record, actor, tool, protocol, evidence, quality, safety and derivation record", "description": "Immutable or successor-versioned evidence-bearing procedure record for source record, actor, tool, protocol, evidence, quality, safety and derivation.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus source-record-actor-tool-protocol-evidence-quality-safety-and-derivation assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null }, { "id": "sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit", "name": "Sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit", "description": "Records sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ], "questions": [ { "id": "sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit?", "kind": "privacy", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit, using which evidence, competence and delegated authority?", "kind": "validation", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit, and how may it be validated, challenged, corrected or retained?", "kind": "exception", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit-data", "name": "Sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit data", "description": "Typed procedure-occurrence data for sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ] } ], "artifacts": [ { "id": "sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit-record", "name": "Sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit record", "description": "Immutable or successor-versioned evidence-bearing procedure record for sensitivity, consent, purpose, access, redaction, break-glass, disclosure and audit.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus sensitivity-consent-purpose-access-redaction-break-glass-disclosure-and-audit assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-006", "SRC-010", "SRC-011", "SRC-012", "SRC-014", "SRC-015" ] } ], "inline_only_rationale": null } ] }, { "id": "retention-projection-validation-and-safe-agent-operation", "name": "Retention, projection, validation and safe agent operation", "description": "Groups source-qualified procedure context for retention, projection, validation and safe agent operation.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "findings": [ { "id": "retention-hold-disposition-tombstone-correction-duty-and-external-record-policy", "name": "Retention, hold, disposition, tombstone, correction duty and external record policy", "description": "Records retention, hold, disposition, tombstone, correction duty and external record policy as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "questions": [ { "id": "retention-hold-disposition-tombstone-correction-duty-and-external-record-policy-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish retention, hold, disposition, tombstone, correction duty and external record policy?", "kind": "retention", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "retention-hold-disposition-tombstone-correction-duty-and-external-record-policy-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported retention, hold, disposition, tombstone, correction duty and external record policy, using which evidence, competence and delegated authority?", "kind": "process", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "retention-hold-disposition-tombstone-correction-duty-and-external-record-policy-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to retention, hold, disposition, tombstone, correction duty and external record policy, and how may it be validated, challenged, corrected or retained?", "kind": "provenance", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "retention-hold-disposition-tombstone-correction-duty-and-external-record-policy-data", "name": "Retention, hold, disposition, tombstone, correction duty and external record policy data", "description": "Typed procedure-occurrence data for retention, hold, disposition, tombstone, correction duty and external record policy with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "retention-hold-disposition-tombstone-correction-duty-and-external-record-policy-record", "name": "Retention, hold, disposition, tombstone, correction duty and external record policy record", "description": "Immutable or successor-versioned evidence-bearing procedure record for retention, hold, disposition, tombstone, correction duty and external record policy.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus retention-hold-disposition-tombstone-correction-duty-and-external-record-policy assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null }, { "id": "fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip", "name": "FHIR, openEHR, SNOMED, ICHI, OMOP, UDI projection, version, loss and round-trip", "description": "Records fhir, openehr, snomed, ichi, omop, udi projection, version, loss and round-trip as source-qualified procedure-occurrence context while preserving external clinical masters and the separation among request, performance, result, report and adverse event.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ], "questions": [ { "id": "fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip-q01", "text": "Which stable identities, procedure classes, performed values and explicit unknowns establish fhir, openehr, snomed, ichi, omop, udi projection, version, loss and round-trip?", "kind": "interoperability", "answer_data": [ "identifiers and classifications", "planned and performed values", "unknown and not-applicable states" ] }, { "id": "fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip-q02", "text": "Who requested, authorized, performed, assisted, recorded or reported fhir, openehr, snomed, ichi, omop, udi projection, version, loss and round-trip, using which evidence, competence and delegated authority?", "kind": "temporal", "answer_data": [ "participants and roles", "evidence and competence", "authority and limitations" ] }, { "id": "fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip-q03", "text": "Which scheduled, occurrence, performer, recorded, reported and knowledge times apply to fhir, openehr, snomed, ichi, omop, udi projection, version, loss and round-trip, and how may it be validated, challenged, corrected or retained?", "kind": "privacy", "answer_data": [ "distinct event and record times", "validation and challenge", "successor correction and retention" ] } ], "data_elements": [ { "id": "fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip-data", "name": "FHIR, openEHR, SNOMED, ICHI, OMOP, UDI projection, version, loss and round-trip data", "description": "Typed procedure-occurrence data for fhir, openehr, snomed, ichi, omop, udi projection, version, loss and round-trip with source, authority, event time, status, evidence and provenance.", "value_kind": "collection", "cardinality": "0..n", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "artifacts": [ { "id": "fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip-record", "name": "FHIR, openEHR, SNOMED, ICHI, OMOP, UDI projection, version, loss and round-trip record", "description": "Immutable or successor-versioned evidence-bearing procedure record for fhir, openehr, snomed, ichi, omop, udi projection, version, loss and round-trip.", "media_or_form": [ "logical procedure assertion", "request binding, safety check, event, outcome, evidence or projection record" ], "serial": true, "identity_strategy": "Procedure occurrence ID plus fhir-openehr-snomed-ichi-omop-udi-projection-version-loss-and-round-trip assertion or event ID; patient, code, date, encounter and billing claim never identify the occurrence alone.", "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "inline_only_rationale": null } ] } ] } ] }, "functions": [ { "id": "register-procedure-occurrence", "name": "Register procedure occurrence", "description": "Governed operation to register procedure occurrence without hidden mutation of external clinical masters.", "inputs": [ "source record", "subject", "profile", "authority" ], "outputs": [ "procedure occurrence root" ], "preconditions": [ "identity, event boundary, subject and source pass" ], "effects": [ "one bounded occurrence exists without creating external masters" ], "source_refs": [ "SRC-001", "SRC-006", "SRC-012", "SRC-015" ] }, { "id": "bind-request-plan-consent-and-indication", "name": "Bind request, plan, consent and indication", "description": "Governed operation to bind request, plan, consent and indication without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "authoritative references", "profile" ], "outputs": [ "source-qualified clinical context binding" ], "preconditions": [ "identity, status, temporal validity and authority pass" ], "effects": [ "plan and authorization context is visible without implying performance" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-010" ] }, { "id": "verify-readiness-and-time-out", "name": "Verify readiness and time-out", "description": "Governed operation to verify readiness and time-out without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "subject, site and procedure", "team", "checklist profile" ], "outputs": [ "immutable verification events" ], "preconditions": [ "identity, site, consent, equipment and team participation pass" ], "effects": [ "recorded checks precede the governed performance point" ], "source_refs": [ "SRC-010", "SRC-011" ] }, { "id": "start-or-resume-procedure", "name": "Start or resume procedure", "description": "Governed operation to start or resume procedure without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "authorization", "readiness", "expected status" ], "outputs": [ "in-progress status event" ], "preconditions": [ "allowed transition, performer, location and start time pass" ], "effects": [ "performance begins or resumes without mutating the order" ], "source_refs": [ "SRC-001", "SRC-006" ] }, { "id": "record-performed-components-and-deviations", "name": "Record performed components and deviations", "description": "Governed operation to record performed components and deviations without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "methods, sites and resources", "planned baseline" ], "outputs": [ "performed technique and deviation assertions" ], "preconditions": [ "sequence, part-of, source, actor and event-time checks pass" ], "effects": [ "actual performance remains distinguishable from intent" ], "source_refs": [ "SRC-001", "SRC-007", "SRC-008", "SRC-009" ] }, { "id": "hold-stop-abort-or-record-nonperformance", "name": "Hold, stop, abort or record non-performance", "description": "Governed operation to hold, stop, abort or record non-performance without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "reason", "authority", "safety state" ], "outputs": [ "status or non-performance event" ], "preconditions": [ "allowed transition, reason, impact and follow-up pass" ], "effects": [ "an interrupted or not-done procedure is explicit and never treated as completed" ], "source_refs": [ "SRC-001", "SRC-002", "SRC-006" ] }, { "id": "complete-and-record-immediate-outcome", "name": "Complete and record immediate outcome", "description": "Governed operation to complete and record immediate outcome without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "performed summary", "outcome evidence" ], "outputs": [ "completion event and outcome assertion" ], "preconditions": [ "performed scope, responsible party, outputs and unresolved risks pass" ], "effects": [ "completion is recorded without claiming success or long-term benefit" ], "source_refs": [ "SRC-001", "SRC-005", "SRC-010" ] }, { "id": "link-reports-complications-and-adverse-events", "name": "Link reports, complications and adverse events", "description": "Governed operation to link reports, complications and adverse events without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "reports and observations", "harm or condition references" ], "outputs": [ "typed output and safety links" ], "preconditions": [ "source, causality status, severity and access pass" ], "effects": [ "related clinical records remain independent and attributable" ], "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-015" ] }, { "id": "amend-correct-or-replace-procedure-record", "name": "Amend, correct or replace procedure record", "description": "Governed operation to amend, correct or replace procedure record without hidden mutation of external clinical masters.", "inputs": [ "prior occurrence", "correction", "reason", "responsible party" ], "outputs": [ "successor record and revision link" ], "preconditions": [ "identity, non-overwrite, provenance and safety-impact pass" ], "effects": [ "consumers distinguish current use from historical documentation" ], "source_refs": [ "SRC-001", "SRC-006", "SRC-014", "SRC-015" ] }, { "id": "project-retain-disclose-and-audit", "name": "Project, retain, disclose and audit", "description": "Governed operation to project, retain, disclose and audit without hidden mutation of external clinical masters.", "inputs": [ "occurrence", "target profile", "access and retention policies" ], "outputs": [ "projection, disclosure, tombstone or disposition event" ], "preconditions": [ "mapping loss, privacy, hold, correction duty and idempotency pass" ], "effects": [ "context remains interoperable, reconstructable and protected" ], "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-009", "SRC-012", "SRC-013", "SRC-014", "SRC-015", "SRC-016" ] } ], "composition": [ { "target": "WM-ACT-049 Care Plan / Episode", "relation": "REFERENCE", "purpose": "Record candidate inverse containment and planning context without approving the ledger edge or cascade semantics.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003" ] }, { "target": "WM-ACT-014 Health Care Delivery, WM-ACT-018 Encounter, ServiceRequest, Appointment, Task, Consent and Procedure Definition models", "relation": "REFERENCE", "purpose": "Bind system context, intent, scheduling, workflow and authority while their masters retain lifecycle.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-006" ] }, { "target": "Patient, Practitioner, Organization, Care Team, Location, Device, Substance, Medication, Specimen and product models", "relation": "REFERENCE", "purpose": "Resolve authoritative subjects, performers, sites and used or manipulated items without copying them.", "required": true, "source_refs": [ "SRC-001", "SRC-006", "SRC-007", "SRC-008", "SRC-013" ] }, { "target": "WM-ACT-046 Clinical Observation / Diagnosis, DiagnosticReport, Condition, AdverseEvent, follow-up, evidence, provenance, consent, audit and record models", "relation": "REFERENCE", "purpose": "Bind outputs, safety consequences, evidence and governance without lifecycle or causality cascade.", "required": false, "source_refs": [ "SRC-001", "SRC-004", "SRC-005", "SRC-014", "SRC-015" ] }, { "target": "FHIR R5, openEHR RM 1.1.0, SNOMED CT, ICHI, OMOP CDM 5.4 and UDI", "relation": "ALIGN", "purpose": "Project version-pinned clinical, workflow, classifier, analytic and device views with maturity, jurisdiction and information-loss declarations.", "required": false, "source_refs": [ "SRC-001", "SRC-002", "SRC-003", "SRC-004", "SRC-005", "SRC-006", "SRC-007", "SRC-008", "SRC-009", "SRC-012", "SRC-013" ] } ], "serviceLayers": { "dimension": { "owner_package_requirements": [ "Dimension owner and medical-procedure governance mandate", "Patient, practitioner, organization, encounter, request, plan, consent, location, device, substance, specimen, observation, report, condition, adverse-event, audit and record registries", "Approved procedure profiles, code and device releases, safety checklists, authority and validation rules", "Privacy, consent, correction, disclosure, retention and agent policies" ], "namespace_guidance": "Mint procedure occurrence, component, verification, performer, resource-use, outcome, deviation, status, revision, disclosure and event IDs; preserve every source-system and device identifier.", "registry_links": [ "https://ver.cy/models/", "https://ver.cy/model-agent-protocol.md" ] }, "canon_and_patch": { "canonicalization_rules": [ "Canonicalize by authoritative source-system procedure occurrence identifier, source organization, subject binding and lineage head, never patient, code, date, encounter, invoice or claim alone.", "Keep procedure definition, request, plan, appointment, workflow task, performed occurrence, observation, report, complication, adverse event and follow-up instruction distinct." ], "patch_rules": [ "Extensions declare specialty, jurisdiction, terminology, safety, authority, device, lifecycle, privacy, retention and interoperability effects.", "Released performance, status, outcome, resource-use and safety-check records are immutable; corrections create linked successors.", "Never silently change subject, requested or performed procedure, body site, approach, performer, device, consent, time, status, outcome, complication link, access or provenance." ], "compatibility_rules": [ "Ignore additive fields only when identity, event boundary, subject, performed meaning, authority, status, time, safety and provenance survive.", "Every exchange or classifier projection pins version, code system, profile and information-loss declaration." ] }, "artifact_rules": { "identity_priority": [ "Authoritative master-system procedure occurrence identifier qualified by source organization and occurrence profile.", "Governed globally resolvable procedure occurrence IRI.", "Dimension UUID when neither preceding identifier exists." ], "timestamp_rule": "Use RFC 3339 timestamps with seconds and explicit offset or Z; distinguish scheduled, preparation, start, stop, completion, performer, specimen, device, recorded, reported, ingested, observation and knowledge times whenever they differ.", "serial_naming_rule": "Use {procedure-occurrence-id}--{component-status-or-event-id}--{artifact-kind}--{revision-id}.", "integrity_rule": "Store digest, media type, profile, subject and source binding, terminology and device versions, actor, event and knowledge times, status, access marking and provenance." }, "policies": [ "The procedure occurrence is not a reusable Procedure Definition, ServiceRequest, CarePlan, Appointment, Task, Encounter, Consent, Patient, Practitioner, Organization, Location, Device, Substance, Medication, Specimen, Observation, DiagnosticReport, Condition, AdverseEvent, Claim, Audit or Record master.", "Order, schedule, readiness, performance, completion, success, observation, report, complication and adverse event remain separate.", "A completed status proves only that the recorded occurrence reached completion under its source, not that it succeeded or caused a later outcome.", "Agents cannot authorize, start, stop, alter, diagnose, attribute harm, implant or remove a device, disclose data or dispose records outside explicit role and policy authority." ], "crud": { "read": [ "Resolve access purpose, occurrence profile, source, subject, request and consent bindings, performed definition, participants, times, status, resources, outcomes, reports, complications, lineage, holds and projection loss." ], "create": [ "Bind stable occurrence identity, event boundary, source, subject, responsible authority, request or ad hoc basis and expected procedure before recording performance." ], "update": [ "Append successor readiness checks, performance details, deviations, statuses, outcomes, links and corrections with reason, authority, expected revision, event time and knowledge time." ], "delete": [ "Apply patient-safety, clinical-record, device, privacy, legal-hold and adopting-Dimension retention policy; retire or tombstone this occurrence without cascading to Patient, Encounter, Request, Device, Observation, Report, Condition, AdverseEvent or other masters, and let the external records policy execute physical disposition." ] }, "roles": [ { "name": "Procedure occurrence steward", "responsibilities": [ "Own occurrence boundary, profile, namespace, lifecycle and quality rules." ] }, { "name": "Requester or care-plan owner", "responsibilities": [ "Own external request, indication, priority and intended outcome." ] }, { "name": "Responsible performer", "responsibilities": [ "Own performed scope, technique, status, deviations and immediate outcome within competence." ] }, { "name": "Procedure team member", "responsibilities": [ "Own role-qualified participation and safety-check evidence." ] }, { "name": "Recorder or reporter", "responsibilities": [ "Preserve source fidelity and distinguish primary performance evidence from reported history." ] }, { "name": "Clinical safety reviewer", "responsibilities": [ "Own readiness, complication, adverse-event and correction impact review." ] }, { "name": "Terminology and device steward", "responsibilities": [ "Own versioned code, UDI and projection mappings with loss declarations." ] }, { "name": "Privacy, records and assurance steward", "responsibilities": [ "Own protected views, disclosures, holds, retention and auditability." ] } ], "access": { "default_rule": "Deny procedure, diagnosis, device, reproductive, mental-health, genetic, imaging and other sensitive clinical context unless a purpose-bound policy permits the minimum necessary view.", "scopes": [ "bundle", "layer", "finding", "artifact" ], "exceptions": [ "Declared subject, guardian, care team, emergency, public-health, research, regulator, court or legally authorized access must cite authority, scope, purpose and time limit where applicable and must be logged." ], "audit_requirements": [ "Log actor, agent, role, purpose, occurrence, operation, authority, policy, RFC 3339 time, affected fields, source revision and outcome without duplicating unnecessary clinical content." ] }, "agents_bootstrap": { "filename": "AGENTS.md", "required_fields": [ "Name", "Type", "Specification URL", "Storage type URL", "Interface URL", "Processes URL" ], "read_order": [ "Read Dimension clinical safety, scope-of-practice, consent, device, terminology, privacy, access, correction, records and agent policies.", "Read this model and linked request, care plan, patient, encounter, consent, performer, location, device, substance, specimen, observation, report, condition, adverse-event and audit models before mutation." ] } }, "coverage": { "claim": "WM-ACT-047 covers one source-qualified medical procedure occurrence or explicit non-performance from request and authorization bindings through readiness, performance, immediate outcome, output and safety links, correction, protected use, retention and projection. It separates the event from procedure definitions, requests, plans, schedules, tasks, encounters, consent, participants, devices, observations, reports, conditions, adverse events and records. Specialty profiles, jurisdiction rules, the candidate Care Plan containment edge, implementation testing and independent external review remain deferred.", "confidence": "medium", "checklist": [ { "dimension": "identity", "status": "covered", "notes": "Identity is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "classification and definition", "status": "covered", "notes": "Classification and definition is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "direct properties", "status": "covered", "notes": "Direct properties is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "recognition and observation", "status": "covered", "notes": "Recognition and observation is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "capabilities and possible actions", "status": "covered", "notes": "Capabilities and possible actions is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "composition", "status": "covered", "notes": "Composition is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "lifecycle", "status": "covered", "notes": "Lifecycle is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "relationships", "status": "covered", "notes": "Relationships is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "temporal", "status": "covered", "notes": "Temporal is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "spatial", "status": "covered", "notes": "Spatial is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "provenance", "status": "covered", "notes": "Provenance is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "ownership and stewardship", "status": "covered", "notes": "Ownership and stewardship is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "validation and quality", "status": "covered", "notes": "Validation and quality is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "access and privacy", "status": "covered", "notes": "Access and privacy is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "retention and deletion", "status": "covered", "notes": "Retention and deletion is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." }, { "dimension": "interoperability", "status": "covered", "notes": "Interoperability is explicit; specialty profiles, jurisdiction rules, approved care-plan containment and independently validated mappings remain held where applicable." } ], "known_omissions": [ "Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.", "WM-ACT-049 Care Plan / Episode CONTAINS WM-ACT-047 is candidate metadata and not an approved composition edge.", "Surgery, anesthesia, imaging, laboratory, rehabilitation, counseling, obstetric, dental, device, transfusion and other procedure families require specialty profiles.", "FHIR R5 Procedure, ServiceRequest, CarePlan and AdverseEvent are Trial Use at varied maturity; ICHI is a current development publication and full SNOMED, OMOP and UDI interoperability requires release-pinned testing." ], "conflicts": [ "Procedure definition, order, appointment, task, performed occurrence, result, report, complication and adverse event are not interchangeable.", "Completed status does not establish success, benefit, absence of complications or causal attribution.", "Source fidelity, normalized procedure coding, patient safety, privacy, correction rights and record retention can conflict and require attributable governance." ], "regional_assumptions": [ "Consent, performer qualification, scope of practice, time-out, reporting, retention and disclosure rules depend on jurisdiction, specialty, setting and urgency.", "Joint Commission and FDA sources are United States profiles; WHO safety materials are adaptable rather than complete local law.", "Procedure codes, device identifiers and reimbursement classifications vary by jurisdiction and may not encode the actual technique performed." ], "adversarial_checks": [ "Reject an occurrence without stable identity, event boundary, source, subject, responsible authority, status, occurrence time and lineage head.", "Reject an order represented as performance, completed represented as successful, complication represented as proven causation or reported history represented as primary evidence.", "Reject wrong-person, wrong-site or wrong-procedure readiness assertions without attributable verification under the applicable profile.", "Reject corrections that overwrite prior performed details, device use, status, outcomes, complications, reports or authorship.", "Reject autonomous authorization, procedure control, harm attribution, device manipulation, clinical action, disclosure or disposition outside explicit authority." ] }, "researchAdjudication": { "providerMode": "single-provider-waiver", "activeProviders": [ "codex" ], "waivedProviders": [ "claude", "grok" ], "providerPolicy": { "contract_version": "1.0.0", "mode": "single-provider-waiver", "effective_at": "2026-09-06T00:00:00Z", "scope": "Canonical single-stream subject-model research after the six-workstream consolidation", "active_providers": [ "codex" ], "waived_providers": [ { "provider": "claude", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "Claude produced no result on prior 1800-second and 900-second attempts and again timed out on bounded 600-second Sonnet and 300-second Haiku passes. The owner prioritized completion over provider availability." }, { "provider": "grok", "authorized_by": "repository owner", "authorized_at": "2026-09-06T00:00:00Z", "reason": "The repository owner authorized completion without Grok when Grok is unavailable, slow or schema-invalid. Grok may still be attempted as a bounded supplemental reviewer, but its failure never blocks a valid Claude plus no-tools result." } ], "review_rule": "Codex may complete source-grounded fallback research after bounded Claude and Grok attempts fail. It requires a separate no-tools adversarial audit and remains reviewable-draft with a visible absence-of-external-review hold.", "supplemental_provider_attempts": [ { "provider": "claude", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." }, { "provider": "grok", "required": false, "maximum_attempts": 1, "failure_policy": "record-and-continue", "admission_rule": "Use only a locally schema-valid result whose sources and boundaries survive adjudication." } ] }, "boundaryDecision": { "entry_kind": "event", "status": "accepted", "rationale": "The subject-model entry kind event is sound because the model represents one procedure occurrence, attempt or explicit non-performance with occurrence identity, subject, performers, time, status and consequences. The frozen registry record_plane is world-model and its catalogue entry_kind is standalone-mm; neither is the model-research schema entry_kind axis." }, "decisions": [ { "concept": "Procedure definition, request, plan, task and occurrence separation", "disposition": "accepted", "rationale": "FHIR and openEHR support distinct reusable definitions, requests or instructions, workflow fulfillment and performed action records. The event owns what was attempted or done and binds external intent without absorbing it." }, { "concept": "Performed technique and planned procedure separation", "disposition": "accepted", "rationale": "Procedure code, method, site, approach, components, devices and deviations record actual performance independently of the request. The event never treats scheduling, readiness or an order as proof of performance." }, { "concept": "Completion, outcome, observation, complication and adverse-event separation", "disposition": "accepted", "rationale": "Completed status proves only event completion. Immediate outcome, measured observations, reports, complications and adverse events remain distinct source-qualified records, and a relation does not prove causation." }, { "concept": "WM-ACT-049 Care Plan containment", "disposition": "deferred", "rationale": "The registry ledger records Care Plan / Episode CONTAINS WM-ACT-047 as candidate metadata. The specification may reference planning context but may not publish this edge as approved or infer cascade behavior." }, { "concept": "Safety verification and authority", "disposition": "accepted-with-profile-hold", "rationale": "WHO and Joint Commission sources support subject, site, procedure, consent and team verification, but exact checkpoints, exceptions and authority require specialty, institution and jurisdiction profiles." }, { "concept": "Immutable correction and reported-source distinction", "disposition": "accepted", "rationale": "Released performance, device-use, status and outcome records are not overwritten. Corrections create successors, and primary performance evidence remains distinguishable from reported history or billing-derived data." }, { "concept": "Standards maturity and projection scope", "disposition": "accepted", "rationale": "FHIR R5 Procedure and ServiceRequest are Trial Use at maturity level 4, CarePlan and AdverseEvent are Trial Use at maturity level 2, FHIR Observation is normative, and ICHI is a development publication. Every FHIR, openEHR, SNOMED, ICHI, OMOP and UDI alignment must pin version and loss; no universal conformance is claimed." }, { "concept": "Single-provider waiver", "disposition": "accepted-with-mandatory-hold", "rationale": "One Claude Sonnet and one Grok 4.6 attempt for WM-ACT-047 each timed out after 120 seconds. Owner-approved policy permits source-grounded Codex fallback after this separate no-tools audit. Confidence remains medium and assurance remains reviewable-draft with a visible absence-of-external-review hold." } ], "publicationHolds": [ "Absence-of-external-review hold: one Claude Sonnet and one Grok 4.6 attempt for WM-ACT-047 each timed out after 120 seconds. No external result was admitted; the model remains a reviewable draft after the separate no-tools audit.", "Registry edge approval hold: WM-ACT-049 Care Plan / Episode CONTAINS WM-ACT-047 remains candidate metadata. This blocks complete relationship claims, not standalone reviewable-draft publication.", "Clinical-specialty hold: surgery, anesthesia, imaging, laboratory, rehabilitation, counseling, obstetric, dental, device, transfusion and other procedure families need specialized method, resource, safety, outcome and follow-up rules.", "Jurisdiction and institution hold: consent, qualification, scope of practice, time-out, reporting, retention, correction and disclosure must bind applicable policy before operational use.", "Interoperability hold: FHIR resource maturity varies, ICHI is a development publication, and all FHIR, openEHR, SNOMED, ICHI, OMOP and UDI projections require version-pinned mappings, licensing checks where applicable, loss declarations and clinical validation.", "Independent external review was explicitly waived by the repository owner; this codex-only result remains a reviewable draft." ], "deferredResearch": [ "Approve or reject the WM-ACT-049 containment edge and define cardinality, plan membership, performed-activity binding and non-cascade semantics.", "Create specialty profiles for surgery, anesthesia, imaging, laboratory, rehabilitation, counseling, obstetric, dental, device and transfusion procedures.", "Create jurisdiction and institution profiles for consent, performer qualification, safety verification, reporting, correction, retention and access.", "Test release-pinned FHIR, openEHR, SNOMED CT, ICHI, OMOP CDM and UDI mappings with mapping-loss and round-trip evidence.", "Obtain supplemental Claude or Grok review and resolve any material challenge before canonical promotion." ] }, "statistics": { "sources": 16, "bundles": 6, "layers": 12, "findings": 24, "questions": 72, "artifacts": 24, "functions": 10 } }