minimal Common Oncology Data Elements (mCODE) Implementation Guide
2.1.0 - STU 2.1
minimal Common Oncology Data Elements (mCODE) Implementation Guide
2.1.0 - STU 2.1
This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v2.1.0: STU 2) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-related-surgical-procedure | Version: 2.1.0 | |||
| Active as of 2023-03-21 | Computable Name: CancerRelatedSurgicalProcedure | |||
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, one of which is required.
Procedure resources associated with an in-scope patient with Procedure.category SNOMED CT 387713003 MAY 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. Specifically, any surgical procedure related to the treatment of a PrimaryCancerCondition or SecondaryCancerCondition SHOULD published in this form.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreProcedureProfile
| 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 |
  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) |
  category | 1..1 | CodeableConcept | Classification of the 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 | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003 | |
| code | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) | |
| subject | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on | |
| reasonCode | S | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) |
 reasonReference | S | 0..* | Reference(Primary Cancer Condition Profile | Secondary Cancer Condition Profile) | The justification that the procedure was performed |
| bodySite | S | 0..* | CodeableConcept | Target body sites |
| extension | S | 0..* | Extension | Extension |
| locationQualifier | S | 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 | S | 0..1 | CodeableConcept | Laterality qualifier (excluding laterality) 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 |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVS |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| 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) |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 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: 387713003 | |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
 performed[x] | SΣ | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| 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 | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| locationQualifier | S | 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 | S | 0..1 | CodeableConcept | Laterality qualifier (excluding laterality) 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.category | example | Pattern: SNOMED CT code 387713003 |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVS |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| 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) | ||||
| 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 | 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 | ||||
| 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 | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) | ||||
| 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 | When the procedure was performed | |||||
| performedDateTime | dateTime S | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| 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 | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| locationQualifier | S | 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 | S | 0..1 | CodeableConcept | Laterality qualifier (excluding laterality) 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 | 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 |
This structure is derived from USCoreProcedureProfile
Summary
Mandatory: 1 element
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from USCoreProcedureProfile
| 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 |
| 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) |
| category | 1..1 | CodeableConcept | Classification of the 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 | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003 | |
| code | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) | |
| subject | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on | |
| reasonCode | S | 0..* | CodeableConcept | Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) |
| reasonReference | S | 0..* | Reference(Primary Cancer Condition Profile | Secondary Cancer Condition Profile) | The justification that the procedure was performed |
| bodySite | S | 0..* | CodeableConcept | Target body sites |
| extension | S | 0..* | Extension | Extension |
| locationQualifier | S | 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 | S | 0..1 | CodeableConcept | Laterality qualifier (excluding laterality) 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 |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVS |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| 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) |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 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: 387713003 | |
| code | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) |
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
| performed[x] | SΣ | 1..1 | When the procedure was performed | |
| performedDateTime | dateTime | |||
| 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 | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| locationQualifier | S | 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 | S | 0..1 | CodeableConcept | Laterality qualifier (excluding laterality) 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.category | example | Pattern: SNOMED CT code 387713003 |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVS |
| Procedure.reasonCode | extensible | CancerDisorderVS |
| Procedure.bodySite | example | SNOMEDCTBodyStructures |
| 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) | ||||
| 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 | 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 | ||||
| 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 | SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) | ||||
| 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 | When the procedure was performed | |||||
| performedDateTime | dateTime S | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| 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 | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| locationQualifier | S | 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 | S | 0..1 | CodeableConcept | Laterality qualifier (excluding laterality) 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 | 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 |
This structure is derived from USCoreProcedureProfile
Summary
Mandatory: 1 element
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
IG © 2022+ HL7 International Clinical Interoperability Council. Package hl7.fhir.us.mcode#2.1.0 based on FHIR 4.0.1. Generated 2023-03-21
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