IDEA4RC FHIR Implementation Guide
0.1.0 - CI Build
150
IDEA4RC FHIR Implementation Guide
0.1.0 - CI Build
150
IDEA4RC FHIR Implementation Guide, published by IDEA4RC Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/idea4rc/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/Procedure-otherTreatment-eu-i4rc | Version: 0.1.0 | |||
| Draft as of 2024-11-12 | Computable Name: ProcedureOtherTreatI4rc | |||
This profile defines how to represent Other Treatment procedures in FHIR for describing a set of Surgery data required by the IDEA4RC project. This porfiles is adapted from the PanCareSurPass Procedure Surgery profile.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |
  status |
1..1 | code | State of the procedure | |
| code |
0..1 | CodeableConcept | Identification of the procedure. | |
 subject |
1..1 | Reference(Patient: IDEA4RC) | Who the procedure was performed on | |
  Slices for performed[x] |
1..1 | dateTime, Period, string, Age, Range | When the procedure was performed Slice: Unordered, Open by type:$this | |
   performed[x]:performedPeriod |
0..1 | Period | Date of the surgical procedure | |
| reasonReference |
1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed | |
 outcome |
0..1 | CodeableConcept | ADD VOC BINDING | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | State of the procedure Binding: EventStatus (required): A code specifying the state of the procedure. |
 code |
Σ | 0..1 | CodeableConcept | Identification of the procedure. Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject |
Σ | 1..1 | Reference(Patient: IDEA4RC) | Who the procedure was performed on |
| Slices for performed[x] |
Σ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |
 performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Date of the surgical procedure |
| reasonReference |
Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed |
| outcome |
Σ | 0..1 | CodeableConcept | ADD VOC BINDING Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | |
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||
| 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 | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| 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 |
?!Σ | 1..1 | code | State of the procedure Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
| 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 |
Σ | 0..1 | CodeableConcept | Identification of the procedure. Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject |
Σ | 1..1 | Reference(Patient: IDEA4RC) | Who the procedure was performed on | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| Slices for performed[x] |
Σ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Date of the surgical procedure | ||||
| 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 |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed | ||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome |
Σ | 0..1 | CodeableConcept | ADD VOC BINDING 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-status|4.0.1from 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 | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| 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 |
This structure is derived from Procedure
Summary
Mandatory: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |
| status |
1..1 | code | State of the procedure | |
| code |
0..1 | CodeableConcept | Identification of the procedure. | |
| subject |
1..1 | Reference(Patient: IDEA4RC) | Who the procedure was performed on | |
| Slices for performed[x] |
1..1 | dateTime, Period, string, Age, Range | When the procedure was performed Slice: Unordered, Open by type:$this | |
| performed[x]:performedPeriod |
0..1 | Period | Date of the surgical procedure | |
| reasonReference |
1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed | |
| outcome |
0..1 | CodeableConcept | ADD VOC BINDING | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!Σ | 1..1 | code | State of the procedure Binding: EventStatus (required): A code specifying the state of the procedure. |
| code |
Σ | 0..1 | CodeableConcept | Identification of the procedure. Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . |
| subject |
Σ | 1..1 | Reference(Patient: IDEA4RC) | Who the procedure was performed on |
| Slices for performed[x] |
Σ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performedString |
string | |||
| performedAge |
Age | |||
| performedRange |
Range | |||
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Date of the surgical procedure |
| reasonReference |
Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed |
| outcome |
Σ | 0..1 | CodeableConcept | ADD VOC BINDING Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Procedure.status | required | EventStatushttp://hl7.org/fhir/ValueSet/event-status|4.0.1from the FHIR Standard | |
| Procedure.code | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | |
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-outcomefrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
0..* | Procedure | An action that is being or was performed on a patient | |||||
| 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 | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| 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 |
?!Σ | 1..1 | code | State of the procedure Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
| 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 |
Σ | 0..1 | CodeableConcept | Identification of the procedure. Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . | ||||
| subject |
Σ | 1..1 | Reference(Patient: IDEA4RC) | Who the procedure was performed on | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
| Slices for performed[x] |
Σ | 1..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performedString |
string | |||||||
| performedAge |
Age | |||||||
| performedRange |
Range | |||||||
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Date of the surgical procedure | ||||
| 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 |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed | ||||
| bodySite |
Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome |
Σ | 0..1 | CodeableConcept | ADD VOC BINDING 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-status|4.0.1from 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 | example | ProcedureCodes(SNOMEDCT)http://hl7.org/fhir/ValueSet/procedure-codefrom the FHIR Standard | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodeshttp://hl7.org/fhir/ValueSet/performer-rolefrom the FHIR Standard | ||||
| Procedure.reasonCode | example | ProcedureReasonCodeshttp://hl7.org/fhir/ValueSet/procedure-reasonfrom the FHIR Standard | ||||
| 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 |
This structure is derived from Procedure
Summary
Mandatory: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2022+ IDEA4RC Project. Package hl7.eu.fhir.idea4rc#0.1.0 based on FHIR 4.0.1. Generated 2024-11-12
Links: Table of Contents |
QA Report
The IDEA4RC project has received funding from the European Union's Horizon 2020
research and innovation programme under grant agreement No. 101057048.
