minimal Common Oncology Data Elements (mCODE) Implementation Guide
1.16.0 - STU Release 2 (Ballot Version)
minimal Common Oncology Data Elements (mCODE) Implementation Guide
1.16.0 - STU Release 2 (Ballot Version)
This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v1.16.0: STU 2 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 
| Defining URL: | http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-course-summary |
| Version: | 1.16.0 |
| Name: | RadiotherapyCourseSummary |
| Title: | Radiotherapy Course Summary |
| Status: | Active as of 2021-04-15T12:44:45+00:00 |
| Definition: | 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. To describe the treatment in more detail, use either TeleradiotherapyTreatmentPhase or BrachytherapyTreatmentPhase, which should reference this summary through their partOf elements. Whether the course has been fully delivered or stopped is indicated in the status element. |
| Publisher: | HL7 International Clinical Interoperability Council |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-course-summary
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 represented by different profiles, TeleradiotherapyTreatmentPhase and BrachytherapyTreatmentPhase.
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 mCODE 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.
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
Summary
Mandatory: 1 element
Must-Support: 11 elements
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 mcode-reason-required: One of reasonCode or reasonReference SHALL be present |
  id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
 mcode-treatment-intent | S | 0..1 | CodeableConcept | Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required) |
| mcode-treatment-termination-reason | S | 0..1 | CodeableConcept | Termination Reason URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) |
 mcode-radiotherapy-modality | S | 0..* | CodeableConcept | Radiotherapy Modality URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality |
  id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..0 | |||
| url | 1..1 | uri | "http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality" | |
 value[x] | 0..1 | CodeableConcept | Value of extension Binding: Radiotherapy Modality Value Set (required) | |
| mcode-radiotherapy-technique | S | 0..* | CodeableConcept | Radiotherapy Technique URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-technique |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..0 | |||
| url | 1..1 | uri | "http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-technique" | |
| value[x] | 0..1 | CodeableConcept | Value of extension Binding: Radiotherapy Technique Value Set (required) | |
| mcode-radiotherapy-sessions | S | 0..1 | unsignedInt | Radiotherapy Number of Sessions URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions |
| mcode-radiotherapy-dose-delivered-to-volume | S | 0..* | (Complex) | Radiotherapy Dose Delivered To Body Volume 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 | ?!SΣ | 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 | SΣ | 1..1 | CodeableConcept | Classification 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 |
| 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: 108290001 | |
| 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 | SΣ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II 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://hl7.org/fhir/us/mcode/CodeSystem/mcode-resource-identifier-cs | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mcode-radiotherapy-course-summary | |
| 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(US Core Patient Profile) | Who the procedure was performed on |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | SΣ | 1..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: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | SΣ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) |
| 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 | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | I | 0..* | USCoreProcedureProfile | An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present |
| extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| mcode-treatment-intent | 0..1 | CodeableConcept | Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required) | |
| mcode-treatment-termination-reason | 0..1 | CodeableConcept | Termination Reason URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) | |
| mcode-radiotherapy-modality | 0..* | CodeableConcept | Radiotherapy Modality URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality | |
| mcode-radiotherapy-technique | 0..* | CodeableConcept | Radiotherapy Technique URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-technique | |
| mcode-radiotherapy-sessions | 0..1 | unsignedInt | Radiotherapy Number of Sessions URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions | |
| mcode-radiotherapy-dose-delivered-to-volume | 0..* | (Complex) | Radiotherapy Dose Delivered To Body Volume URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-dose-delivered-to-volume | |
| status | ?!Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| category | Σ | 1..1 | CodeableConcept | Classification 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 |
 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 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 108290001 | |
| code | Σ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II 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://hl7.org/fhir/us/mcode/CodeSystem/mcode-resource-identifier-cs | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mcode-radiotherapy-course-summary | |
| subject | Σ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
| performed[x] | Σ | 1..1 | Period | When the procedure was performed |
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | Σ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) |
| Documentation for this format | ||||
This structure is derived from USCoreProcedureProfile
Summary
Mandatory: 1 element
Must-Support: 11 elements
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 mcode-reason-required: One of reasonCode or reasonReference SHALL be present |
| id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| mcode-treatment-intent | S | 0..1 | CodeableConcept | Treatment Intent URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-intent Binding: Treatment Intent Value Set (required) |
| mcode-treatment-termination-reason | S | 0..1 | CodeableConcept | Termination Reason URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-treatment-termination-reason Binding: Treatment Termination Reason Value Set (required) |
| mcode-radiotherapy-modality | S | 0..* | CodeableConcept | Radiotherapy Modality URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..0 | |||
| url | 1..1 | uri | "http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-modality" | |
| value[x] | 0..1 | CodeableConcept | Value of extension Binding: Radiotherapy Modality Value Set (required) | |
| mcode-radiotherapy-technique | S | 0..* | CodeableConcept | Radiotherapy Technique URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-technique |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..0 | |||
| url | 1..1 | uri | "http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-technique" | |
| value[x] | 0..1 | CodeableConcept | Value of extension Binding: Radiotherapy Technique Value Set (required) | |
| mcode-radiotherapy-sessions | S | 0..1 | unsignedInt | Radiotherapy Number of Sessions URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-radiotherapy-sessions |
| mcode-radiotherapy-dose-delivered-to-volume | S | 0..* | (Complex) | Radiotherapy Dose Delivered To Body Volume 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 | ?!SΣ | 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 | SΣ | 1..1 | CodeableConcept | Classification 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 |
| 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: 108290001 | |
| 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 | SΣ | 1..1 | CodeableConcept | Procedure codes from SNOMED CT, CPT, or HCPCS II 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://hl7.org/fhir/us/mcode/CodeSystem/mcode-resource-identifier-cs | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: mcode-radiotherapy-course-summary | |
| 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(US Core Patient Profile) | Who the procedure was performed on |
| encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of |
| performed[x] | SΣ | 1..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: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. |
| reasonReference | SΣ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed |
| bodySite | SΣ | 0..* | CodeableConcept | All body structure(s) treated Binding: Radiotherapy Treatment Location Value Set (required) |
| 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 | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| Procedure.language | preferred | CommonLanguages Max Binding: AllLanguages |
| Procedure.extension:modality.value[x] | required | RadiotherapyModalityVS |
| Procedure.extension:technique.value[x] | required | RadiotherapyTechniqueVS |
| Procedure.status | required | EventStatus |
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) |
| Procedure.category | example | Pattern: SNOMED CT code 108290001 |
| Procedure.code | extensible | Pattern: mcode-radiotherapy-course-summary |
| Procedure.performer.function | example | ProcedurePerformerRoleCodes |
| Procedure.reasonCode | example | ProcedureReasonCodes |
| 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 |
| Id | Path | Details | Requirements |
| mcode-reason-required | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
IG © 2019+ HL7 International Clinical Interoperability Council. Package hl7.fhir.us.mcode#1.16.0 based on FHIR 4.0.1. Generated 2021-04-15
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