minimal Common Oncology Data Elements (mCODE) Implementation Guide
4.0.0-ballot - STU4 Ballot
minimal Common Oncology Data Elements (mCODE) Implementation Guide
4.0.0-ballot - STU4 Ballot
minimal Common Oncology Data Elements (mCODE) Implementation Guide, published by HL7 International / Clinical Interoperability Council. This guide is not an authorized publication; it is the continuous build for version 4.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-mCODE-ig/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-cancer-related-surgical-procedure | Version: 4.0.0-ballot | |||
| Active as of 2024-04-09 | Maturity Level: 3 | Computable Name: CancerRelatedSurgicalProcedure | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.15.42.10 | ||||
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:
Changes since version true:
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 (extensible) |
 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(US Core Condition Problems and Health Concerns 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 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 | URI |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vsfrom this IG | |
| Procedure.reasonCode | extensible | CancerDisorderVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vsfrom this IG |
| 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 us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' 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 (extensible) |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
 code |
SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
  performed[x] |
SΣC | 0..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(US Core Condition Problems and Health Concerns 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 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 | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vsfrom this IG | |
| Procedure.reasonCode | extensible | CancerDisorderVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vsfrom this IG | |
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard |
| 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 us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' 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 (extensible) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code |
SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: 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] |
SΣC | 0..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(US Core Condition Problems and Health Concerns 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 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 | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vsfrom this IG | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | extensible | CancerDisorderVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vsfrom this IG | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| mcode-reason-required | warning | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
This structure is derived from USCoreProcedureProfile
Summary
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 3
Differential View
This structure is derived from USCoreProcedureProfile
| 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 (extensible) |
| 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(US Core Condition Problems and Health Concerns 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 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 | URI |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vsfrom this IG | |
| Procedure.reasonCode | extensible | CancerDisorderVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vsfrom this IG |
| 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 us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' 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 (extensible) |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) |
| code |
SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who the procedure was performed on |
| performed[x] |
SΣC | 0..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(US Core Condition Problems and Health Concerns 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 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 | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | |
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vsfrom this IG | |
| Procedure.reasonCode | extensible | CancerDisorderVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vsfrom this IG | |
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard |
| 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 us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' 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 (extensible) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | External Identifiers for this procedure | ||||
| instantiatesCanonical |
Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri |
Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn |
Σ | 0..* | Reference(CarePlan | ServiceRequest) | A request for this procedure | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣC | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) | ||||
| statusReason |
Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| category |
Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code |
SΣ | 1..1 | CodeableConcept | Identification of the procedure Binding: 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] |
SΣC | 0..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(US Core Condition Problems and Health Concerns 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 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 | URI | |||
| Procedure.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-statusfrom the FHIR Standard | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT)http://hl7.org/fhir/ValueSet/procedure-not-performed-reasonfrom the FHIR Standard | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-categoryfrom the FHIR Standard | ||||
| Procedure.code | extensible | CancerRelatedSurgicalProcedureVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vsfrom this IG | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | extensible | CancerDisorderVShttp://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vsfrom this IG | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructureshttp://hl7.org/fhir/ValueSet/body-sitefrom the FHIR Standard | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard | ||||
| Procedure.complication | example | Condition/Problem/DiagnosisCodeshttp://hl7.org/fhir/ValueSet/condition-codefrom the FHIR Standard | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-followupfrom the FHIR Standard | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodeshttp://hl7.org/fhir/ValueSet/device-actionfrom the FHIR Standard | ||||
| Procedure.usedCode | example | FHIRDeviceTypeshttp://hl7.org/fhir/ValueSet/device-kindfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| mcode-reason-required | warning | Procedure | One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists() |
This structure is derived from USCoreProcedureProfile
Summary
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Interoperability Council. Package hl7.fhir.us.mcode#4.0.0-ballot based on FHIR 4.0.1. Generated 2024-04-09
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