HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU Ballot 1

This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v0.9.1: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

AbnormalBodyStructure

 

The official URL for this profile is: 

http://hl7.org/fhir/us/mcode/StructureDefinition/obf-AbnormalBodyStructure

A body structure such as wound or tumor, observed to be present in a patient. The body structure is a condition that persists over time. The Code represents the body structure itself (the morphology), while the BodyLocation is the location of that structure. This corresponds to FHIR R4, where the BodyStructure resource has morphology (corresponding to Code) and a location. For example, the Code could be blunt force injury (SCT 3821009) and location left knee.

This profile builds on USCoreCondition.

This profile was published on Thu Aug 01 00:00:00 EDT 2019 as a active by HL7 International Clinical Interoperability Council.

Summary

Mandatory: 0 element (2 nested mandatory elements)

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

obf.AbnormalBodyStructure maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.source
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  ClinicalStatus maps to clinicalStatus
  Status maps to verificationStatus
  Category maps to category
  Severity maps to severity
  Code maps to code
  BodyLocation.Code maps to bodySite
  BodyLocation.Laterality maps to bodySite.extension
  BodyLocation.AnatomicalOrientation maps to bodySite.extension
  BodyLocation.RelationToLandmark maps to bodySite.extension
  SubjectOfRecord maps to subject
  CareContext maps to encounter
  Onset maps to onset[x]
  Abatement maps to abatement[x]
  StatementDateTime maps to recordedDate
  Author maps to recorder
  PersonInformationSource maps to asserter
  StageInformation maps to stage
  StageInformation.StageSummary maps to stage.summary
  StageInformation.StageDetail maps to stage.assessment
  StageInformation.Type maps to stage.type
  Evidence.Manifestation maps to evidence.code
  Evidence.Resource maps to evidence.detail
  Annotation maps to note
  DateOfDiagnosis maps to http://hl7.org/fhir/StructureDefinition/condition-assertedDate
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition obf-AbnormalBodyStructure
... extension Slice: Unordered, Open by value:url
... condition-assertedDate 0..1dateTimeDate the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... verificationStatus 1..1
... category 1..1
... code Binding: AbnormalBodyStructureVS (extensible)
... bodySite Binding: BodyLocationVS (preferred)
.... obf-datatype-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-Laterality-extension
Binding: Laterality (extensible)
.... obf-datatype-AnatomicalOrientation-extension 0..*CodeableConceptAnatomicalOrientation
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-AnatomicalOrientation-extension
Binding: AnatomicalOrientationVS (extensible)
.... obf-datatype-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-RelationToLandmark-extension
... subject Reference(obf-Patient)
... encounter Reference(US Core Encounter Profile)
... recorder Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | obf-Patient | RelatedPerson)
... asserter Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson)
... stage 0..1
.... assessment 0..1Reference(obf-Observation | obf-DiagnosticReport)
... evidence
.... code Binding: SNOMEDCTClinicalFindings (example)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*obf-AbnormalBodyStructure
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... condition-assertedDate 0..1dateTimeDate the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣI1..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category S1..1CodeableConceptproblem-list-item | encounter-diagnosis
Binding: US Core Condition Category Codes (extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: AbnormalBodyStructureVS (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: BodyLocationVS (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... obf-datatype-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-Laterality-extension
Binding: Laterality (extensible)
.... obf-datatype-AnatomicalOrientation-extension 0..*CodeableConceptAnatomicalOrientation
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-AnatomicalOrientation-extension
Binding: AnatomicalOrientationVS (extensible)
.... obf-datatype-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-RelationToLandmark-extension
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(obf-Patient)Who has the condition?
... encounter Σ0..1Reference(US Core Encounter Profile)Encounter created as part of
... onset[x] Σ0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, Age, Period, Range, stringWhen in resolution/remission
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | obf-Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example)
.... assessment I0..1Reference(obf-Observation | obf-DiagnosticReport)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example)
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: SNOMEDCTClinicalFindings (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Summary

Mandatory: 0 element (2 nested mandatory elements)

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

obf.AbnormalBodyStructure maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.source
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  ClinicalStatus maps to clinicalStatus
  Status maps to verificationStatus
  Category maps to category
  Severity maps to severity
  Code maps to code
  BodyLocation.Code maps to bodySite
  BodyLocation.Laterality maps to bodySite.extension
  BodyLocation.AnatomicalOrientation maps to bodySite.extension
  BodyLocation.RelationToLandmark maps to bodySite.extension
  SubjectOfRecord maps to subject
  CareContext maps to encounter
  Onset maps to onset[x]
  Abatement maps to abatement[x]
  StatementDateTime maps to recordedDate
  Author maps to recorder
  PersonInformationSource maps to asserter
  StageInformation maps to stage
  StageInformation.StageSummary maps to stage.summary
  StageInformation.StageDetail maps to stage.assessment
  StageInformation.Type maps to stage.type
  Evidence.Manifestation maps to evidence.code
  Evidence.Resource maps to evidence.detail
  Annotation maps to note
  DateOfDiagnosis maps to http://hl7.org/fhir/StructureDefinition/condition-assertedDate

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition obf-AbnormalBodyStructure
... extension Slice: Unordered, Open by value:url
... condition-assertedDate 0..1dateTimeDate the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... verificationStatus 1..1
... category 1..1
... code Binding: AbnormalBodyStructureVS (extensible)
... bodySite Binding: BodyLocationVS (preferred)
.... obf-datatype-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-Laterality-extension
Binding: Laterality (extensible)
.... obf-datatype-AnatomicalOrientation-extension 0..*CodeableConceptAnatomicalOrientation
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-AnatomicalOrientation-extension
Binding: AnatomicalOrientationVS (extensible)
.... obf-datatype-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-RelationToLandmark-extension
... subject Reference(obf-Patient)
... encounter Reference(US Core Encounter Profile)
... recorder Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | obf-Patient | RelatedPerson)
... asserter Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson)
... stage 0..1
.... assessment 0..1Reference(obf-Observation | obf-DiagnosticReport)
... evidence
.... code Binding: SNOMEDCTClinicalFindings (example)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Condition I0..*obf-AbnormalBodyStructure
us-core-1: A code in Condition.category SHOULD be from US Core Condition Category Codes value set.
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... condition-assertedDate 0..1dateTimeDate the condition was first asserted
URL: http://hl7.org/fhir/StructureDefinition/condition-assertedDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Ids for this condition
... clinicalStatus ?!SΣI0..1CodeableConceptactive | recurrence | relapse | inactive | remission | resolved
Binding: ConditionClinicalStatusCodes (required)
... verificationStatus ?!SΣI1..1CodeableConceptunconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Binding: ConditionVerificationStatus (required)
... category S1..1CodeableConceptproblem-list-item | encounter-diagnosis
Binding: US Core Condition Category Codes (extensible)
... severity 0..1CodeableConceptSubjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred)
... code SΣ1..1CodeableConceptIdentification of the condition, problem or diagnosis
Binding: AbnormalBodyStructureVS (extensible)
... bodySite Σ0..*CodeableConceptAnatomical location, if relevant
Binding: BodyLocationVS (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... obf-datatype-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-Laterality-extension
Binding: Laterality (extensible)
.... obf-datatype-AnatomicalOrientation-extension 0..*CodeableConceptAnatomicalOrientation
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-AnatomicalOrientation-extension
Binding: AnatomicalOrientationVS (extensible)
.... obf-datatype-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/mcode/StructureDefinition/obf-datatype-RelationToLandmark-extension
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(obf-Patient)Who has the condition?
... encounter Σ0..1Reference(US Core Encounter Profile)Encounter created as part of
... onset[x] Σ0..1dateTime, Age, Period, Range, stringEstimated or actual date, date-time, or age
... abatement[x] I0..1dateTime, Age, Period, Range, stringWhen in resolution/remission
... recordedDate Σ0..1dateTimeDate record was first recorded
... recorder Σ0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | obf-Patient | RelatedPerson)Who recorded the condition
... asserter Σ0..1Reference(obf-Patient | US Core Practitioner Profile | RelatedPerson)Person who asserts this condition
... stage I0..1BackboneElementStage/grade, usually assessed formally
con-1: Stage SHALL have summary or assessment
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... summary I0..1CodeableConceptSimple summary (disease specific)
Binding: ConditionStage (example)
.... assessment I0..1Reference(obf-Observation | obf-DiagnosticReport)Formal record of assessment
.... type 0..1CodeableConceptKind of staging
Binding: ConditionStageType (example)
... evidence I0..*BackboneElementSupporting evidence
con-2: evidence SHALL have code or details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptManifestation/symptom
Binding: SNOMEDCTClinicalFindings (example)
.... detail ΣI0..*Reference(Resource)Supporting information found elsewhere
... note 0..*AnnotationAdditional information about the Condition

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
Condition.languagepreferredCommonLanguages
Max Binding: AllLanguages
Condition.clinicalStatusrequiredConditionClinicalStatusCodes
Condition.verificationStatusrequiredConditionVerificationStatus
Condition.categoryextensibleUSCoreConditionCategoryCodes
Condition.severitypreferredCondition/DiagnosisSeverity
Condition.codeextensibleAbnormalBodyStructureVS
Condition.bodySitepreferredBodyLocationVS
Condition.stage.summaryexampleConditionStage
Condition.stage.typeexampleConditionStageType
Condition.evidence.codeexampleSNOMEDCTClinicalFindings

 

Constraints

IdPathDetailsRequirements
dom-2ConditionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-4ConditionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3ConditionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-6ConditionA resource should have narrative for robust management
: text.div.exists()
dom-5ConditionIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
con-5ConditionCondition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
: verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
con-4ConditionIf condition is abated, then clinicalStatus must be either inactive, resolved, or remission
: abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-3ConditionCondition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
: clinicalStatus.exists() or verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()
us-core-1ConditionA code in Condition.category SHOULD be from US Core Condition Category Codes value set.
: where(category in 'http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category').exists()
ele-1Condition.stageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-1Condition.stageStage SHALL have summary or assessment
: summary.exists() or assessment.exists()
ele-1Condition.evidenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
con-2Condition.evidenceevidence SHALL have code or details
: code.exists() or detail.exists()