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

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Resource Profile: Procedure: Surgery

This profile defines how to represent 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:

• Use this Resource Profile: Bundle: IDEA4RC
• Refer to this Resource Profile: Procedure: Surgery
• Examples for this Resource Profile: Procedure/procedure-id-29

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
text		0..1	Narrative	Textual description of the surgical procedure ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
ProcedureCategoryR5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
value[x]		1..1		Value of extension Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Additional Bindings Purpose Surgical Procedure Category Preferred Surgery Intention Preferred ele-1: All FHIR elements must have a @value or children
valueBase64Binary			base64Binary
valueBoolean			boolean
valueCanonical			canonical(Any)
valueCode			code
valueDate			date
valueDateTime			dateTime
valueDecimal			decimal
valueId			id
valueInstant			instant
valueInteger			integer
valueMarkdown			markdown
valueOid			oid
valuePositiveInt			positiveInt
valueString			string
valueTime			time
valueUnsignedInt			unsignedInt
valueUri			uri
valueUrl			url
valueUuid			uuid
valueAddress			Address
valueAge			Age
valueAnnotation			Annotation
valueAttachment			Attachment
valueCodeableConcept			CodeableConcept
valueCoding			Coding
valueContactPoint			ContactPoint
valueCount			Count
valueDistance			Distance
valueDuration			Duration
valueHumanName			HumanName
valueIdentifier			Identifier
valueMoney			Money
valuePeriod			Period
valueQuantity			Quantity
valueRange			Range
valueRatio			Ratio
valueReference			Reference(Any)
valueSampledData			SampledData
valueSignature			Signature
valueTiming			Timing
valueContactDetail			ContactDetail
valueContributor			Contributor
valueDataRequirement			DataRequirement
valueExpression			Expression
valueParameterDefinition			ParameterDefinition
valueRelatedArtifact			RelatedArtifact
valueTriggerDefinition			TriggerDefinition
valueUsageContext			UsageContext
valueDosage			Dosage
valueMeta			Meta
ProcedureMethod		0..*	(Complex)	The method used to perform the procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-method ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/procedure-method"
value[x]		1..1	CodeableConcept	Type of surgical approach on Tumour Binding: Type of surgical approach (extensible) ele-1: All FHIR elements must have a @value or children
supportingInfoR5		0..*	Reference(Resource)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	Σ	0..*	Identifier	External Identifiers for this surgical procedure ele-1: All FHIR elements must have a @value or children
partOf	Σ	0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	State of the procedure Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children 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	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient: IDEA4RC)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
performed[x]:performedDateTime	Σ	1..1	dateTime	Date of the surgical procedure ele-1: All FHIR elements must have a @value or children
reasonReference	Σ	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed ele-1: All FHIR elements must have a @value or children
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible) ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
qualifier		0..*	CodeableConcept	Body Location Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (preferred) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
laterality		0..1	(Complex)	Laterality Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
value[x]		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required) ele-1: All FHIR elements must have a @value or children
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: Surgery Outcome (extensible) ele-1: All FHIR elements must have a @value or children
complication		0..*	CodeableConcept	Complication following the procedure Binding: Surgery Complication (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.extension:ProcedureCategoryR5.value[x]	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.extension:ProcedureMethod.value[x]	extensible	VsTypeofSurgicalApproachI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/type-of-surgical-approach-eu-i4rc from this IG
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 387713003 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	SurgicalProcedureTypeVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-surgicalProcedureType-eu-i4rc from this IG
Procedure.bodySite	extensible	AffectedOrganVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-affectedOrgan-eu-i4rc from this IG
Procedure.bodySite.extension:laterality.value[x]	required	LateralityQualifierVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-laterality-qualifier-vs
Procedure.outcome	extensible	VsSurgeryOutcomeI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-outcome-eu-i4rc from this IG
Procedure.complication	required	VsSurgeryComplicationI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-complication-eu-i4rc from this IG

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure			Procedure
text		0..1	Narrative	Textual description of the surgical procedure
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
ProcedureCategoryR5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
value[x]		1..1	base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta	Value of extension Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Additional Bindings Purpose Surgical Procedure Category Preferred Surgery Intention Preferred
ProcedureMethod		0..*	(Complex)	The method used to perform the procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-method
value[x]		1..1	CodeableConcept	Type of surgical approach on Tumour Binding: Type of surgical approach (extensible)
supportingInfoR5		0..*	Reference(Resource)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
identifier		0..*	Identifier	External Identifiers for this surgical procedure
partOf		0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status		1..1	code	State of the procedure
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		0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject		1..1	Reference(Patient: IDEA4RC)	Who the procedure was performed on
Slices for performed[x]		1..1	dateTime	When the procedure was performed Slice: Unordered, Open by type:$this
performed[x]:performedDateTime		1..1	dateTime	Date of the surgical procedure
reasonReference		1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite		0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
Slices for extension				Content/Rules for all slices
qualifier		0..*	CodeableConcept	Body Location Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (preferred)
laterality		0..1	(Complex)	Laterality Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier
value[x]		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
outcome		0..1	CodeableConcept	The result of procedure Binding: Surgery Outcome (extensible)
complication		0..*	CodeableConcept	Complication following the procedure Binding: Surgery Complication (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.extension:ProcedureCategoryR5.value[x]	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.extension:ProcedureMethod.value[x]	extensible	VsTypeofSurgicalApproachI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/type-of-surgical-approach-eu-i4rc from this IG
Procedure.code	extensible	SurgicalProcedureTypeVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-surgicalProcedureType-eu-i4rc from this IG
Procedure.bodySite	extensible	AffectedOrganVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-affectedOrgan-eu-i4rc from this IG
Procedure.bodySite.extension:laterality.value[x]	required	LateralityQualifierVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-laterality-qualifier-vs
Procedure.outcome	extensible	VsSurgeryOutcomeI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-outcome-eu-i4rc from this IG
Procedure.complication	required	VsSurgeryComplicationI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-complication-eu-i4rc from this IG

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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Textual description of the surgical procedure
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
ProcedureCategoryR5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
value[x]		1..1		Value of extension Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Additional Bindings Purpose Surgical Procedure Category Preferred Surgery Intention Preferred
valueBase64Binary			base64Binary
valueBoolean			boolean
valueCanonical			canonical(Any)
valueCode			code
valueDate			date
valueDateTime			dateTime
valueDecimal			decimal
valueId			id
valueInstant			instant
valueInteger			integer
valueMarkdown			markdown
valueOid			oid
valuePositiveInt			positiveInt
valueString			string
valueTime			time
valueUnsignedInt			unsignedInt
valueUri			uri
valueUrl			url
valueUuid			uuid
valueAddress			Address
valueAge			Age
valueAnnotation			Annotation
valueAttachment			Attachment
valueCodeableConcept			CodeableConcept
valueCoding			Coding
valueContactPoint			ContactPoint
valueCount			Count
valueDistance			Distance
valueDuration			Duration
valueHumanName			HumanName
valueIdentifier			Identifier
valueMoney			Money
valuePeriod			Period
valueQuantity			Quantity
valueRange			Range
valueRatio			Ratio
valueReference			Reference(Any)
valueSampledData			SampledData
valueSignature			Signature
valueTiming			Timing
valueContactDetail			ContactDetail
valueContributor			Contributor
valueDataRequirement			DataRequirement
valueExpression			Expression
valueParameterDefinition			ParameterDefinition
valueRelatedArtifact			RelatedArtifact
valueTriggerDefinition			TriggerDefinition
valueUsageContext			UsageContext
valueDosage			Dosage
valueMeta			Meta
ProcedureMethod		0..*	(Complex)	The method used to perform the procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-method
id		0..1	id	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/procedure-method"
value[x]		1..1	CodeableConcept	Type of surgical approach on Tumour Binding: Type of surgical approach (extensible)
supportingInfoR5		0..*	Reference(Resource)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this surgical 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: Surgery)	Reference to the parent surgery procedure
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	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	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
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	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	1..1	dateTime	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: Affected Organs (surgery) (extensible)
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
qualifier		0..*	CodeableConcept	Body Location Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (preferred)
laterality		0..1	(Complex)	Laterality Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
value[x]		1..1	CodeableConcept	Value of extension 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: Surgery Outcome (extensible)
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Surgery Complication (required)
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

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.extension:ProcedureCategoryR5.value[x]	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.extension:ProcedureMethod.value[x]	extensible	VsTypeofSurgicalApproachI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/type-of-surgical-approach-eu-i4rc from this IG
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 387713003 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	SurgicalProcedureTypeVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-surgicalProcedureType-eu-i4rc from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	example	ProcedureReasonCodes http://hl7.org/fhir/ValueSet/procedure-reason from the FHIR Standard
Procedure.bodySite	extensible	AffectedOrganVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-affectedOrgan-eu-i4rc from this IG
Procedure.bodySite.extension:laterality.value[x]	required	LateralityQualifierVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-laterality-qualifier-vs
Procedure.outcome	extensible	VsSurgeryOutcomeI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-outcome-eu-i4rc from this IG
Procedure.complication	required	VsSurgeryComplicationI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-complication-eu-i4rc from this IG
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

This structure is derived from Procedure

Summary

Mandatory: 4 elements

Structures

This structure refers to these other structures:

• Procedure: Surgery (http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/Procedure-surgery-eu-i4rc)
• Patient: IDEA4RC (http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/patient-eu-i4rc)
• Condition: Primary Cancer (http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/Condition-primaryCancer-eu-i4rc)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
• http://hl7.org/fhir/StructureDefinition/procedure-method
• http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
• http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-body-location-qualifier
• http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Procedure.performed[x]

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
text		0..1	Narrative	Textual description of the surgical procedure ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
ProcedureCategoryR5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
value[x]		1..1		Value of extension Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Additional Bindings Purpose Surgical Procedure Category Preferred Surgery Intention Preferred ele-1: All FHIR elements must have a @value or children
valueBase64Binary			base64Binary
valueBoolean			boolean
valueCanonical			canonical(Any)
valueCode			code
valueDate			date
valueDateTime			dateTime
valueDecimal			decimal
valueId			id
valueInstant			instant
valueInteger			integer
valueMarkdown			markdown
valueOid			oid
valuePositiveInt			positiveInt
valueString			string
valueTime			time
valueUnsignedInt			unsignedInt
valueUri			uri
valueUrl			url
valueUuid			uuid
valueAddress			Address
valueAge			Age
valueAnnotation			Annotation
valueAttachment			Attachment
valueCodeableConcept			CodeableConcept
valueCoding			Coding
valueContactPoint			ContactPoint
valueCount			Count
valueDistance			Distance
valueDuration			Duration
valueHumanName			HumanName
valueIdentifier			Identifier
valueMoney			Money
valuePeriod			Period
valueQuantity			Quantity
valueRange			Range
valueRatio			Ratio
valueReference			Reference(Any)
valueSampledData			SampledData
valueSignature			Signature
valueTiming			Timing
valueContactDetail			ContactDetail
valueContributor			Contributor
valueDataRequirement			DataRequirement
valueExpression			Expression
valueParameterDefinition			ParameterDefinition
valueRelatedArtifact			RelatedArtifact
valueTriggerDefinition			TriggerDefinition
valueUsageContext			UsageContext
valueDosage			Dosage
valueMeta			Meta
ProcedureMethod		0..*	(Complex)	The method used to perform the procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-method ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/procedure-method"
value[x]		1..1	CodeableConcept	Type of surgical approach on Tumour Binding: Type of surgical approach (extensible) ele-1: All FHIR elements must have a @value or children
supportingInfoR5		0..*	Reference(Resource)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
identifier	Σ	0..*	Identifier	External Identifiers for this surgical procedure ele-1: All FHIR elements must have a @value or children
partOf	Σ	0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	State of the procedure Binding: EventStatus (required): A code specifying the state of the procedure. ele-1: All FHIR elements must have a @value or children
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. ele-1: All FHIR elements must have a @value or children 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	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient: IDEA4RC)	Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this ele-1: All FHIR elements must have a @value or children
performed[x]:performedDateTime	Σ	1..1	dateTime	Date of the surgical procedure ele-1: All FHIR elements must have a @value or children
reasonReference	Σ	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed ele-1: All FHIR elements must have a @value or children
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible) ele-1: All FHIR elements must have a @value or children
Slices for extension				Content/Rules for all slices
qualifier		0..*	CodeableConcept	Body Location Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (preferred) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
laterality		0..1	(Complex)	Laterality Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
value[x]		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required) ele-1: All FHIR elements must have a @value or children
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: Surgery Outcome (extensible) ele-1: All FHIR elements must have a @value or children
complication		0..*	CodeableConcept	Complication following the procedure Binding: Surgery Complication (required) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
Procedure.extension:ProcedureCategoryR5.value[x]	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.extension:ProcedureMethod.value[x]	extensible	VsTypeofSurgicalApproachI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/type-of-surgical-approach-eu-i4rc from this IG
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status|4.0.1 from the FHIR Standard
Procedure.category	example	Pattern: SNOMED-CT Code 387713003 http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	SurgicalProcedureTypeVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-surgicalProcedureType-eu-i4rc from this IG
Procedure.bodySite	extensible	AffectedOrganVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-affectedOrgan-eu-i4rc from this IG
Procedure.bodySite.extension:laterality.value[x]	required	LateralityQualifierVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-laterality-qualifier-vs
Procedure.outcome	extensible	VsSurgeryOutcomeI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-outcome-eu-i4rc from this IG
Procedure.complication	required	VsSurgeryComplicationI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-complication-eu-i4rc from this IG

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure			Procedure
text		0..1	Narrative	Textual description of the surgical procedure
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
ProcedureCategoryR5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
value[x]		1..1	base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta	Value of extension Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Additional Bindings Purpose Surgical Procedure Category Preferred Surgery Intention Preferred
ProcedureMethod		0..*	(Complex)	The method used to perform the procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-method
value[x]		1..1	CodeableConcept	Type of surgical approach on Tumour Binding: Type of surgical approach (extensible)
supportingInfoR5		0..*	Reference(Resource)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
identifier		0..*	Identifier	External Identifiers for this surgical procedure
partOf		0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status		1..1	code	State of the procedure
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		0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject		1..1	Reference(Patient: IDEA4RC)	Who the procedure was performed on
Slices for performed[x]		1..1	dateTime	When the procedure was performed Slice: Unordered, Open by type:$this
performed[x]:performedDateTime		1..1	dateTime	Date of the surgical procedure
reasonReference		1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite		0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
Slices for extension				Content/Rules for all slices
qualifier		0..*	CodeableConcept	Body Location Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (preferred)
laterality		0..1	(Complex)	Laterality Qualifier URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier
value[x]		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
outcome		0..1	CodeableConcept	The result of procedure Binding: Surgery Outcome (extensible)
complication		0..*	CodeableConcept	Complication following the procedure Binding: Surgery Complication (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.extension:ProcedureCategoryR5.value[x]	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.extension:ProcedureMethod.value[x]	extensible	VsTypeofSurgicalApproachI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/type-of-surgical-approach-eu-i4rc from this IG
Procedure.code	extensible	SurgicalProcedureTypeVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-surgicalProcedureType-eu-i4rc from this IG
Procedure.bodySite	extensible	AffectedOrganVs http://hl7.eu/fhir/ig/idea4rc/ValueSet/vs-affectedOrgan-eu-i4rc from this IG
Procedure.bodySite.extension:laterality.value[x]	required	LateralityQualifierVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-laterality-qualifier-vs
Procedure.outcome	extensible	VsSurgeryOutcomeI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-outcome-eu-i4rc from this IG
Procedure.complication	required	VsSurgeryComplicationI4rc http://hl7.eu/fhir/ig/idea4rc/ValueSet/surgery-complication-eu-i4rc from this IG

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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Textual description of the surgical procedure
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
ProcedureCategoryR5		0..*	(Complex)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
value[x]		1..1		Value of extension Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Additional Bindings Purpose Surgical Procedure Category Preferred Surgery Intention Preferred
valueBase64Binary			base64Binary
valueBoolean			boolean
valueCanonical			canonical(Any)
valueCode			code
valueDate			date
valueDateTime			dateTime
valueDecimal			decimal
valueId			id
valueInstant			instant
valueInteger			integer
valueMarkdown			markdown
valueOid			oid
valuePositiveInt			positiveInt
valueString			string
valueTime			time
valueUnsignedInt			unsignedInt
valueUri			uri
valueUrl			url
valueUuid			uuid
valueAddress			Address
valueAge			Age
valueAnnotation			Annotation
valueAttachment			Attachment
valueCodeableConcept			CodeableConcept
valueCoding			Coding
valueContactPoint			ContactPoint
valueCount			Count
valueDistance			Distance
valueDuration			Duration
valueHumanName			HumanName
valueIdentifier			Identifier
valueMoney			Money
valuePeriod			Period
valueQuantity			Quantity
valueRange			Range
valueRatio			Ratio
valueReference			Reference(Any)
valueSampledData			SampledData
valueSignature			Signature
valueTiming			Timing
valueContactDetail			ContactDetail
valueContributor			Contributor
valueDataRequirement			DataRequirement
valueExpression			Expression
valueParameterDefinition			ParameterDefinition
valueRelatedArtifact			RelatedArtifact
valueTriggerDefinition			TriggerDefinition
valueUsageContext			UsageContext
valueDosage			Dosage
valueMeta			Meta
ProcedureMethod		0..*	(Complex)	The method used to perform the procedure URL: http://hl7.org/fhir/StructureDefinition/procedure-method
id		0..1	id	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/StructureDefinition/procedure-method"
value[x]		1..1	CodeableConcept	Type of surgical approach on Tumour Binding: Type of surgical approach (extensible)
supportingInfoR5		0..*	Reference(Resource)	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this surgical 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: Surgery)	Reference to the parent surgery procedure
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	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	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
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	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	1..1	dateTime	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: Affected Organs (surgery) (extensible)
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url