ICHOM Patient Centered Outcomes Measure Set for Breast Cancer
1.0.0 - trial-use International flag

This page is part of the ICHOM FHIR Implementation Guide: Breast Cancer (v1.0.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: Axilla surgery

Official URL: http://hl7.org/fhir/uv/ichom-breast-cancer/StructureDefinition/axilla-surgery Version: 1.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: AxillaSurgery

Represents if the breast cancer patient received surgery to the axilla during the last year.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... status S1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... category S1..1CodeableConceptClassification of the procedure
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 699455008
..... display1..1stringRepresentation defined by the system
Fixed Value: Operative procedure on axilla
... code S0..1CodeableConceptIdentification of the procedure
Binding: Targeted axilla surgery ValueSet (required)
... Slices for performed[x] 0..1dateTime, Period, string, Age, RangeWhen the procedure was performed
Slice: Unordered, Open by type:$this
.... performed[x]:performedDateTime S0..1dateTimeWhen the procedure was performed
... reasonReference S0..*Reference(Primary Breast Cancer Condition)The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.coderequiredTargetedAxillaSurgeryVS
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 699455008
..... display1..1stringRepresentation defined by the system
Fixed Value: Operative procedure on axilla
... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: Targeted axilla surgery ValueSet (required)
... subject SΣ1..1Reference(Breast cancer patient)Who the procedure was performed on
... Slices for performed[x] Σ0..1When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
.... performed[x]:performedDateTime SΣ0..1dateTimeWhen the procedure was performed
... reasonReference SΣ0..*Reference(Primary Breast Cancer Condition)The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.statusrequiredEventStatus
Procedure.categoryexamplePattern: SNOMED CT code 699455008("Operative procedure on axilla")
Procedure.coderequiredTargetedAxillaSurgeryVS
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ1..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 699455008
..... display1..1stringRepresentation defined by the system
Fixed Value: Operative procedure on axilla
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: Targeted axilla surgery ValueSet (required)
... subject SΣ1..1Reference(Breast cancer patient)Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... Slices for performed[x] Σ0..1When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
.... performed[x]:performedDateTime SΣ0..1dateTimeWhen the procedure was performed
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... 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
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference SΣ0..*Reference(Primary Breast Cancer Condition)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... 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
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexamplePattern: SNOMED CT code 699455008("Operative procedure on axilla")
Procedure.coderequiredTargetedAxillaSurgeryVS
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

This structure is derived from Procedure

Summary

Mandatory: 1 element
Must-Support: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Procedure.performed[x] is sliced based on the value of type:$this

Maturity: 2

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... status S1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
... category S1..1CodeableConceptClassification of the procedure
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 699455008
..... display1..1stringRepresentation defined by the system
Fixed Value: Operative procedure on axilla
... code S0..1CodeableConceptIdentification of the procedure
Binding: Targeted axilla surgery ValueSet (required)
... Slices for performed[x] 0..1dateTime, Period, string, Age, RangeWhen the procedure was performed
Slice: Unordered, Open by type:$this
.... performed[x]:performedDateTime S0..1dateTimeWhen the procedure was performed
... reasonReference S0..*Reference(Primary Breast Cancer Condition)The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.coderequiredTargetedAxillaSurgeryVS

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 699455008
..... display1..1stringRepresentation defined by the system
Fixed Value: Operative procedure on axilla
... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: Targeted axilla surgery ValueSet (required)
... subject SΣ1..1Reference(Breast cancer patient)Who the procedure was performed on
... Slices for performed[x] Σ0..1When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
.... performed[x]:performedDateTime SΣ0..1dateTimeWhen the procedure was performed
... reasonReference SΣ0..*Reference(Primary Breast Cancer Condition)The justification that the procedure was performed

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.statusrequiredEventStatus
Procedure.categoryexamplePattern: SNOMED CT code 699455008("Operative procedure on axilla")
Procedure.coderequiredTargetedAxillaSurgeryVS

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*ProcedureAn action that is being or was performed on a patient
... 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!SΣ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category SΣ1..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 699455008
..... display1..1stringRepresentation defined by the system
Fixed Value: Operative procedure on axilla
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... code SΣ0..1CodeableConceptIdentification of the procedure
Binding: Targeted axilla surgery ValueSet (required)
... subject SΣ1..1Reference(Breast cancer patient)Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... Slices for performed[x] Σ0..1When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
.... performed[x]:performedDateTime SΣ0..1dateTimeWhen the procedure was performed
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... 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
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference SΣ0..*Reference(Primary Breast Cancer Condition)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe 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..*CodeableConceptComplication 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..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... 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
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexamplePattern: SNOMED CT code 699455008("Operative procedure on axilla")
Procedure.coderequiredTargetedAxillaSurgeryVS
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

This structure is derived from Procedure

Summary

Mandatory: 1 element
Must-Support: 6 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element Procedure.performed[x] is sliced based on the value of type:$this

Maturity: 2

 

Other representations of profile: CSV, Excel, Schematron