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

Resource Profile: Procedure: Surgery

Official URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/Procedure-surgery-eu-i4rc Version: 0.1.0
Draft as of 2026-08-07 Computable Name: ProcedureSurgeryI4rc

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.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Textual description of the surgical procedure
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sameHospital 0..1 boolean Same Hospital
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/same-hospital
.... extension:ProcedureCategoryR5 0..* (Complex) Procedure Category
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding Description: (preferred): Additional bindings
Additional BindingsPurpose
Surgical Procedure Category Preferred
Surgery Intention Preferred
.... extension:ProcedureMethod 0..* (Complex) The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... 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)
.... extension:supportingInfoR5 0..* (Complex) R5: Extra information relevant to the procedure (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
Constraints: ext-1
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo"
..... value[x] 0..1 Reference(Observation: Tumor Rupture) Extra information relevant to the procedure
... identifier Σ 0..* Identifier External Identifiers for this surgical 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.
... 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 Category (extensible)
... subject Σ 1..1 Reference(Patient: IDEA4RC) Who the procedure was performed on
... 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
... reasonReference Σ 1..* Reference(Condition: Primary Cancer) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: Surgery Sites (required)
.... Slices for extension Content/Rules for all slices
..... extension: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)
..... extension:laterality 0..1 (Complex) Laterality Qualifier
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier
...... extension 0..0 Extension
Slice: Unordered, Open by value:url
...... url 1..1 uri "http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
...... value[x] 1..1 CodeableConcept Value of extension
Binding: Surgery Site Laterality Qualifier (required)
... outcome Σ 0..1 CodeableConcept The result of procedure
Binding: Surgery Outcome (extensible)
... complication 0..* CodeableConcept Complication following the procedure
Binding: Surgery Complication (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.extension:ProcedureCategoryR5.​value[x] Base preferred Not State Unknown
Procedure.extension:ProcedureMethod.​value[x] Base extensible Type of surgical approach 📦0.1.0 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible Surgical Procedure Category 📦0.1.0 This IG
Procedure.bodySite Base required Surgery Sites 📦0.1.0 This IG
Procedure.bodySite.extension:laterality.​value[x] Base required Surgery Site Laterality Qualifier 📦0.1.0 This IG
Procedure.outcome Base extensible Surgery Outcome 📦0.1.0 This IG
Procedure.complication Base required Surgery Complication 📦0.1.0 This IG

Constraints

Id Grade Path(s) Description Expression

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure Procedure
... text 0..1 Narrative Textual description of the surgical procedure
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sameHospital 0..1 boolean Same Hospital
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/same-hospital
.... extension:ProcedureCategoryR5 0..* (Complex) Procedure Category
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
..... value[x] 0..1 CodeableConcept Value of extension
Binding Description: (preferred): Additional bindings
Additional BindingsPurpose
Surgical Procedure Category Preferred
Surgery Intention Preferred
.... extension: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)
.... extension:supportingInfoR5 0..* (Complex) R5: Extra information relevant to the procedure (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
..... extension 0..0 Extension
..... value[x] 0..1 Reference(Observation: Tumor Rupture) Extra information relevant to the procedure
... identifier 0..* Identifier External Identifiers for this surgical 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 Category (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: Surgery Sites (required)
.... Slices for extension Content/Rules for all slices
..... extension: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)
..... extension: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: Surgery Site Laterality Qualifier (required)
... outcome 0..1 CodeableConcept The result of procedure
Binding: Surgery Outcome (extensible)
... complication 0..* CodeableConcept Complication following the procedure
Binding: Surgery Complication (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.extension:ProcedureCategoryR5.​value[x] Base preferred Not State Unknown
Procedure.extension:ProcedureMethod.​value[x] Base extensible Type of surgical approach 📦0.1.0 This IG
Procedure.code Base extensible Surgical Procedure Category 📦0.1.0 This IG
Procedure.bodySite Base required Surgery Sites 📦0.1.0 This IG
Procedure.bodySite.extension:laterality.​value[x] Base required Surgery Site Laterality Qualifier 📦0.1.0 This IG
Procedure.outcome Base extensible Surgery Outcome 📦0.1.0 This IG
Procedure.complication Base required Surgery Complication 📦0.1.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Textual description of the surgical procedure
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sameHospital 0..1 boolean Same Hospital
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/same-hospital
.... extension:ProcedureCategoryR5 0..* (Complex) Procedure Category
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding Description: (preferred): Additional bindings
Additional BindingsPurpose
Surgical Procedure Category Preferred
Surgery Intention Preferred
.... extension:ProcedureMethod 0..* (Complex) The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... 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)
.... extension:supportingInfoR5 0..* (Complex) R5: Extra information relevant to the procedure (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
Constraints: ext-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo"
..... value[x] 0..1 Reference(Observation: Tumor Rupture) Extra information relevant to the procedure
... 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 Category (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: Surgery Sites (required)
.... 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
..... extension: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)
..... extension: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 Extension
Slice: Unordered, Open by value:url
...... url 1..1 uri "http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
...... value[x] 1..1 CodeableConcept Value of extension
Binding: Surgery Site Laterality Qualifier (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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Procedure.extension:ProcedureCategoryR5.​value[x] Base preferred Not State Unknown
Procedure.extension:ProcedureMethod.​value[x] Base extensible Type of surgical approach 📦0.1.0 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible Surgical Procedure Category 📦0.1.0 This IG
Procedure.performer.​function Base example Procedure Performer Role Codes 📍4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📍4.0.1 FHIR Std.
Procedure.bodySite Base required Surgery Sites 📦0.1.0 This IG
Procedure.bodySite.extension:laterality.​value[x] Base required Surgery Site Laterality Qualifier 📦0.1.0 This IG
Procedure.outcome Base extensible Surgery Outcome 📦0.1.0 This IG
Procedure.complication Base required Surgery Complication 📦0.1.0 This IG
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... text 0..1 Narrative Textual description of the surgical procedure
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sameHospital 0..1 boolean Same Hospital
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/same-hospital
.... extension:ProcedureCategoryR5 0..* (Complex) Procedure Category
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding Description: (preferred): Additional bindings
Additional BindingsPurpose
Surgical Procedure Category Preferred
Surgery Intention Preferred
.... extension:ProcedureMethod 0..* (Complex) The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... 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)
.... extension:supportingInfoR5 0..* (Complex) R5: Extra information relevant to the procedure (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
Constraints: ext-1
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo"
..... value[x] 0..1 Reference(Observation: Tumor Rupture) Extra information relevant to the procedure
... identifier Σ 0..* Identifier External Identifiers for this surgical 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.
... 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 Category (extensible)
... subject Σ 1..1 Reference(Patient: IDEA4RC) Who the procedure was performed on
... 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
... reasonReference Σ 1..* Reference(Condition: Primary Cancer) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: Surgery Sites (required)
.... Slices for extension Content/Rules for all slices
..... extension: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)
..... extension:laterality 0..1 (Complex) Laterality Qualifier
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier
...... extension 0..0 Extension
Slice: Unordered, Open by value:url
...... url 1..1 uri "http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
...... value[x] 1..1 CodeableConcept Value of extension
Binding: Surgery Site Laterality Qualifier (required)
... outcome Σ 0..1 CodeableConcept The result of procedure
Binding: Surgery Outcome (extensible)
... complication 0..* CodeableConcept Complication following the procedure
Binding: Surgery Complication (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.extension:ProcedureCategoryR5.​value[x] Base preferred Not State Unknown
Procedure.extension:ProcedureMethod.​value[x] Base extensible Type of surgical approach 📦0.1.0 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible Surgical Procedure Category 📦0.1.0 This IG
Procedure.bodySite Base required Surgery Sites 📦0.1.0 This IG
Procedure.bodySite.extension:laterality.​value[x] Base required Surgery Site Laterality Qualifier 📦0.1.0 This IG
Procedure.outcome Base extensible Surgery Outcome 📦0.1.0 This IG
Procedure.complication Base required Surgery Complication 📦0.1.0 This IG

Constraints

Id Grade Path(s) Description Expression

Differential View

This structure is derived from Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure Procedure
... text 0..1 Narrative Textual description of the surgical procedure
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sameHospital 0..1 boolean Same Hospital
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/same-hospital
.... extension:ProcedureCategoryR5 0..* (Complex) Procedure Category
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
..... value[x] 0..1 CodeableConcept Value of extension
Binding Description: (preferred): Additional bindings
Additional BindingsPurpose
Surgical Procedure Category Preferred
Surgery Intention Preferred
.... extension: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)
.... extension:supportingInfoR5 0..* (Complex) R5: Extra information relevant to the procedure (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
..... extension 0..0 Extension
..... value[x] 0..1 Reference(Observation: Tumor Rupture) Extra information relevant to the procedure
... identifier 0..* Identifier External Identifiers for this surgical 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 Category (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: Surgery Sites (required)
.... Slices for extension Content/Rules for all slices
..... extension: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)
..... extension: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: Surgery Site Laterality Qualifier (required)
... outcome 0..1 CodeableConcept The result of procedure
Binding: Surgery Outcome (extensible)
... complication 0..* CodeableConcept Complication following the procedure
Binding: Surgery Complication (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.extension:ProcedureCategoryR5.​value[x] Base preferred Not State Unknown
Procedure.extension:ProcedureMethod.​value[x] Base extensible Type of surgical approach 📦0.1.0 This IG
Procedure.code Base extensible Surgical Procedure Category 📦0.1.0 This IG
Procedure.bodySite Base required Surgery Sites 📦0.1.0 This IG
Procedure.bodySite.extension:laterality.​value[x] Base required Surgery Site Laterality Qualifier 📦0.1.0 This IG
Procedure.outcome Base extensible Surgery Outcome 📦0.1.0 This IG
Procedure.complication Base required Surgery Complication 📦0.1.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Textual description of the surgical procedure
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:sameHospital 0..1 boolean Same Hospital
URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/same-hospital
.... extension:ProcedureCategoryR5 0..* (Complex) Procedure Category
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.category"
..... value[x] 0..1 CodeableConcept Value of extension
Binding Description: (preferred): Additional bindings
Additional BindingsPurpose
Surgical Procedure Category Preferred
Surgery Intention Preferred
.... extension:ProcedureMethod 0..* (Complex) The method used to perform the procedure
URL: http://hl7.org/fhir/StructureDefinition/procedure-method
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... 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)
.... extension:supportingInfoR5 0..* (Complex) R5: Extra information relevant to the procedure (new)
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo
Constraints: ext-1
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
Constraints: ext-1
..... url 1..1 uri "http://hl7.org/fhir/5.0/StructureDefinition/extension-Procedure.supportingInfo"
..... value[x] 0..1 Reference(Observation: Tumor Rupture) Extra information relevant to the procedure
... 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 Category (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: Surgery Sites (required)
.... 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
..... extension: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)
..... extension: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 Extension
Slice: Unordered, Open by value:url
...... url 1..1 uri "http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/mcode-laterality-qualifier"
...... value[x] 1..1 CodeableConcept Value of extension
Binding: Surgery Site Laterality Qualifier (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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Procedure.extension:ProcedureCategoryR5.​value[x] Base preferred Not State Unknown
Procedure.extension:ProcedureMethod.​value[x] Base extensible Type of surgical approach 📦0.1.0 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code Base extensible Surgical Procedure Category 📦0.1.0 This IG
Procedure.performer.​function Base example Procedure Performer Role Codes 📍4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📍4.0.1 FHIR Std.
Procedure.bodySite Base required Surgery Sites 📦0.1.0 This IG
Procedure.bodySite.extension:laterality.​value[x] Base required Surgery Site Laterality Qualifier 📦0.1.0 This IG
Procedure.outcome Base extensible Surgery Outcome 📦0.1.0 This IG
Procedure.complication Base required Surgery Complication 📦0.1.0 This IG
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression

 

Other representations of profile: CSV, Excel, Schematron