minimal Common Oncology Data Elements (mCODE) Implementation Guide
3.0.0-ballot - 2023May
minimal Common Oncology Data Elements (mCODE) Implementation Guide
3.0.0-ballot - 2023May
This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v3.0.0-ballot: STU 3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-course-summary | Version: 3.0.0-ballot | |||
| Active as of 2023-03-28 | Maturity Level: 3 | Computable Name: RadiotherapyCourseSummary | ||
A summary of a course of radiotherapy delivered to a patient. It records the treatment intent, termination reason, modalities, techniques, number of sessions, and doses delivered to one or more body volumes. Whether the course has been fully delivered or stopped is indicated in the status element.
This profile is used to capture a course of radiotherapy delivered to a patient. A course of therapy systematically addresses a condition or set of related conditions. The course can include multiple sessions, can be divided into multiple phases, and can last for several months. A course of treatment has a distinct beginning and end. While the Radiotherapy Course Summary can be incrementally updated as the treatment progresses, the primary purpose is to summarize the entire course of treatment from beginning to end. The status element indicates whether the treatment is in progress or complete.
In radiotherapy, a phase is a subset of a course. A phase is defined as a treatment consisting of one or more identical fractions. Phases are modeled in the forthcoming CODEX Radiation Therapy IG.
The relationship between a course and its phases is exemplified in the following diagram:
In this example, the radiotherapy course encompasses three phases. The course summary captures each radiotherapy volume, the total dose for each volume, and total number of fractions delivered for each volume. The course summary also records the modalities and techniques used, without directly associating those with individual volumes. Other elements in the summary include the reason for treatment, the treatment intent, the period of treatment, and the total number of sessions.
At the phase level, each phase consists of a set of identical fractions. In this context, identical means that each fraction uses the same modality, technique, dose per fraction, and is applied to the same volume or volumes. Because of their spatial relationship or the technique used, all volumes do not necessarily receive the same total dose during a phase. Phases may occur in parallel, overlap, or in alternating temporal patterns.
Procedure resources whose code is mcode-radiotherapy-course-summary (code system http://hl7.org/fhir/us/mcode/CodeSystem/mcode-resource-identifier-cs) MUST conform to this profile. Beyond this requirement, a producer of resources SHOULD ensure that any resource instance associated with an in-scope patient that would reasonably be expected to conform to this profile SHOULD be published in this form. Any resource intended to conform to this profile SHOULD populate meta.profile accordingly.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
| Path | Conformance | ValueSet |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | required | RadiotherapyTreatmentLocationVS |
| Id | Grade | Path(s) | Details | Requirements |
| mcode-reason-required | warning | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present |
  implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
 treatmentIntent | S | 0..1 | CodeableConcept | Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (required) |
| terminationReason | S | 0..1 | CodeableConcept | Treatment Termination Reason Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) |
| modalityAndTechnique | SC | 0..* | (Complex) | Radiotherapy Modality And Technique Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality-and-technique |
| actualNumberOfSessions | S | 0..1 | unsignedInt | Radiotherapy Number of Sessions Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions |
| doseDeliveredToVolume | S | 0..* | (Complex) | Radiotherapy Dose Delivered To Volume Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-dose-delivered-to-volume |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
  code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version | 1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008 | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1217123003 | |
 subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | Who the procedure was performed on |
| performed[x] | SΣC | 0..1 | Period | When the procedure was performed |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) |
| reasonReference | SΣ | 0..* | Reference(Primary Cancer Condition Profile | Secondary Cancer Condition Profile) | The justification that the procedure was performed |
| bodySite | SΣ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) |
| locationQualifier | 0..* | CodeableConcept | General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required) | |
| lateralityQualifier | 0..1 | CodeableConcept | Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.status | required | EventStatus |
| Procedure.code | extensible | Pattern: SNOMED CT code 1217123003 |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | required | RadiotherapyTreatmentLocationVS |
| Id | Grade | Path(s) | Details | Requirements |
| mcode-reason-required | warning | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| treatmentIntent | S | 0..1 | CodeableConcept | Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (required) | ||||
| terminationReason | S | 0..1 | CodeableConcept | Treatment Termination Reason Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) | ||||
| modalityAndTechnique | SC | 0..* | (Complex) | Radiotherapy Modality And Technique Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality-and-technique | ||||
| actualNumberOfSessions | S | 0..1 | unsignedInt | Radiotherapy Number of Sessions Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions | ||||
| doseDeliveredToVolume | S | 0..* | (Complex) | Radiotherapy Dose Delivered To Volume Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-dose-delivered-to-volume | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version | 1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008 | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1217123003 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | Who the procedure was performed on | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣC | 0..1 | Period | When the procedure was performed | ||||
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) | ||||
| reasonReference | SΣ | 0..* | Reference(Primary Cancer Condition Profile | Secondary Cancer Condition Profile) | The justification that the procedure was performed | ||||
| bodySite | SΣ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| locationQualifier | 0..* | CodeableConcept | General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required) | |||||
| lateralityQualifier | 0..1 | CodeableConcept | Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required) | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | 0..* | Annotation | Additional information about the procedure | |||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | EventStatus | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | ||||
| Procedure.code | extensible | Pattern: SNOMED CT code 1217123003 | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | ||||
| Procedure.reasonCode | extensible | CancerDisorderVS | ||||
| Procedure.bodySite | required | RadiotherapyTreatmentLocationVS | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
This structure is derived from USCoreProcedureProfile
Summary
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 3
Differential View
This structure is derived from USCoreProcedureProfile
| Path | Conformance | ValueSet |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | required | RadiotherapyTreatmentLocationVS |
| Id | Grade | Path(s) | Details | Requirements |
| mcode-reason-required | warning | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| treatmentIntent | S | 0..1 | CodeableConcept | Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (required) |
| terminationReason | S | 0..1 | CodeableConcept | Treatment Termination Reason Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) |
| modalityAndTechnique | SC | 0..* | (Complex) | Radiotherapy Modality And Technique Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality-and-technique |
| actualNumberOfSessions | S | 0..1 | unsignedInt | Radiotherapy Number of Sessions Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions |
| doseDeliveredToVolume | S | 0..* | (Complex) | Radiotherapy Dose Delivered To Volume Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-dose-delivered-to-volume |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version | 1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1217123003 | |
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | Who the procedure was performed on |
| performed[x] | SΣC | 0..1 | Period | When the procedure was performed |
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) |
| reasonReference | SΣ | 0..* | Reference(Primary Cancer Condition Profile | Secondary Cancer Condition Profile) | The justification that the procedure was performed |
| bodySite | SΣ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) |
| locationQualifier | 0..* | CodeableConcept | General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required) | |
| lateralityQualifier | 0..1 | CodeableConcept | Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Procedure.status | required | EventStatus |
| Procedure.code | extensible | Pattern: SNOMED CT code 1217123003 |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | required | RadiotherapyTreatmentLocationVS |
| Id | Grade | Path(s) | Details | Requirements |
| mcode-reason-required | warning | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | C | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present | ||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| treatmentIntent | S | 0..1 | CodeableConcept | Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (required) | ||||
| terminationReason | S | 0..1 | CodeableConcept | Treatment Termination Reason Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) | ||||
| modalityAndTechnique | SC | 0..* | (Complex) | Radiotherapy Modality And Technique Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality-and-technique | ||||
| actualNumberOfSessions | S | 0..1 | unsignedInt | Radiotherapy Number of Sessions Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions | ||||
| doseDeliveredToVolume | S | 0..* | (Complex) | Radiotherapy Dose Delivered To Volume Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-dose-delivered-to-volume | ||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn | Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: US Core Procedure Codes (extensible): Codes describing the type of Procedure Required Pattern: At least the following | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version | 1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008 | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 1217123003 | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| subject | SΣ | 1..1 | Reference(Cancer Patient Profile) | Who the procedure was performed on | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| performed[x] | SΣC | 0..1 | Period | When the procedure was performed | ||||
| recorder | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | SΣ | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) | ||||
| reasonReference | SΣ | 0..* | Reference(Primary Cancer Condition Profile | Secondary Cancer Condition Profile) | The justification that the procedure was performed | ||||
| bodySite | SΣ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| locationQualifier | 0..* | CodeableConcept | General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required) | |||||
| lateralityQualifier | 0..1 | CodeableConcept | Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required) | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. | |||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | 0..* | Annotation | Additional information about the procedure | |||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | EventStatus | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | ||||
| Procedure.code | extensible | Pattern: SNOMED CT code 1217123003 | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | ||||
| Procedure.reasonCode | extensible | CancerDisorderVS | ||||
| Procedure.bodySite | required | RadiotherapyTreatmentLocationVS | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodes | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
This structure is derived from USCoreProcedureProfile
Summary
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International Clinical Interoperability Council. Package hl7.fhir.us.mcode#3.0.0-ballot based on FHIR 4.0.1. Generated 2023-03-28
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