HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1
1.0.0 - STU1
HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1
1.0.0 - STU1
This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v1.0.0: STU 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 
A surgical action addressing a cancer condition. The scope of this profile has been narrowed to cancer-related procedures by constraining the ReasonReference and ReasonCode to cancer conditions. Conformance note: If an ICD-10-PCS code is used in the code attribute, and there is a semantically equivalent SNOMED CT or CPT code, the resulting Procedure instance will not be compliant with US Core Profiles.
The official URL for this profile is:
http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-related-surgical-procedure
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
Summary
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
This structure is derived from USCoreProcedureProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | I | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient |
  id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
 mcode-treatment-intent | SI | 0..1 | CodeableConcept | Optional Extensions Element URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical | ΣI | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
| instantiatesUri | ΣI | 0..* | uri | Instantiates external protocol or definition |
 basedOn | ΣI | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| partOf | ΣI | 0..* | Reference(Procedure) | Part of referenced event |
| status | ?!SΣI | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | ΣI | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
 category | ΣI | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) 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 | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003 | |
| 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 | |
| code | SΣI | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible) |
| subject | SΣI | 1..1 | Reference(Cancer Patient) | Who the procedure was performed on |
| encounter | ΣI | 0..1 | Reference(Encounter) | Encounter created as part of |
 performed[x] | SΣI | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| recorder | ΣI | 0..1 | Reference(Practitioner | PractitionerRole) | Who recorded the procedure |
| asserter | ΣI | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure |
| performer | ΣI | 0..* | BackboneElement | The people who performed the procedure |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | ΣI | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example) |
| actor | ΣI | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | The reference to the practitioner |
| onBehalfOf | I | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for |
| location | ΣI | 0..1 | Reference(Location) | Where the procedure happened |
| reasonCode | SΣI | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) |
| reasonReference | SΣI | 0..* | Reference(Cancer Condition Parent) | The justification that the procedure was performed |
| bodySite | SΣI | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| mcode-laterality | SI | 0..1 | CodeableConcept | Optional Extensions Element URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| outcome | ΣI | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
| report | I | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure |
| complication | I | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) |
| complicationDetail | I | 0..* | Reference(Condition) | A condition that is a result of the procedure |
| followUp | I | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) |
| note | I | 0..* | Annotation | Additional information about the procedure |
| focalDevice | I | 0..* | BackboneElement | Manipulated, implanted, or removed device |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| action | I | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred) |
| manipulated | I | 1..1 | Reference(Device) | Device that was changed |
| usedReference | I | 0..* | Reference(Device | Medication | Substance) | Items used during procedure |
| usedCode | I | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example) |
| Documentation for this format | ||||
This structure is derived from USCoreProcedureProfile
Summary
Must-Support: 5 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from USCoreProcedureProfile
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | I | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| mcode-treatment-intent | SI | 0..1 | CodeableConcept | Optional Extensions Element URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | External Identifiers for this procedure |
| instantiatesCanonical | ΣI | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition |
| instantiatesUri | ΣI | 0..* | uri | Instantiates external protocol or definition |
| basedOn | ΣI | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure |
| partOf | ΣI | 0..* | Reference(Procedure) | Part of referenced event |
| status | ?!SΣI | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| statusReason | ΣI | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example) |
| category | ΣI | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example) 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 | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003 | |
| 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 | |
| code | SΣI | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II Binding: Cancer-Related Surgical Procedure Value Set (extensible) |
| subject | SΣI | 1..1 | Reference(Cancer Patient) | Who the procedure was performed on |
| encounter | ΣI | 0..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | SΣI | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| recorder | ΣI | 0..1 | Reference(Practitioner | PractitionerRole) | Who recorded the procedure |
| asserter | ΣI | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure |
| performer | ΣI | 0..* | BackboneElement | The people who performed the procedure |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function | ΣI | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example) |
| actor | ΣI | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | The reference to the practitioner |
| onBehalfOf | I | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for |
| location | ΣI | 0..1 | Reference(Location) | Where the procedure happened |
| reasonCode | SΣI | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) |
| reasonReference | SΣI | 0..* | Reference(Cancer Condition Parent) | The justification that the procedure was performed |
| bodySite | SΣI | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| mcode-laterality | SI | 0..1 | CodeableConcept | Optional Extensions Element URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality |
| coding | ΣI | 0..* | Coding | Code defined by a terminology system |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| outcome | ΣI | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example) |
| report | I | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure |
| complication | I | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example) |
| complicationDetail | I | 0..* | Reference(Condition) | A condition that is a result of the procedure |
| followUp | I | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example) |
| note | I | 0..* | Annotation | Additional information about the procedure |
| focalDevice | I | 0..* | BackboneElement | Manipulated, implanted, or removed device |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| action | I | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred) |
| manipulated | I | 1..1 | Reference(Device) | Device that was changed |
| usedReference | I | 0..* | Reference(Device | Medication | Substance) | Items used during procedure |
| usedCode | I | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example) |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| Procedure.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Procedure.status | required | EventStatus |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) |
| Procedure.category | example | Pattern: SNOMED CT code 387713003 |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVS |
| Procedure.performer.function | example | ProcedurePerformerRoleCodes |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| 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 |
| Id | Path | Details | Requirements |
IG © 2019+ HL7 International Clinical Interoperability Council. Package hl7.fhir.us.mcode#1.0.0 based on FHIR 4.0.1. Generated 2020-03-18
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