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
| Draft as of 2024-11-12 |
Definitions for the Surgery logical model.
Guidance on how to interpret the contents of this table can be found here
| 0. Surgery | |||||||
| Definition | Surgery | ||||||
| Short | Surgery | ||||||
| Logical Model | Instances of this logical model are not marked to be the target of a Reference | ||||||
| 2. Surgery.episodeEvent | |||||||
| Definition | EpisodeEvent element containing the data regarding the patient's cancer | ||||||
| Short | Episode Event reference | ||||||
| Control | 1..1 | ||||||
| Type | http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/EpisodeEvent | ||||||
| Obligations |
| ||||||
| 4. Surgery.type | |||||||
| Definition | Primary surgery/re-excision (check with unplanned or excisional biopsy) | ||||||
| Short | Surgery type | ||||||
| Comments | Primary surgery/re-excision (check with unplanned or excisional biopsy) Surgical procedure - 4301351 Local excision - 4315400 Amputation - 4217482 Limb operation - 4181193 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 6. Surgery.hospital | |||||||
| Definition | Whether or not a surgical procedure was performed and whether it was performed at the registering hospital or another hospital. Diagnostic procedures (biopsy) are not included. | ||||||
| Short | Surgery Hospital | ||||||
| Comments | Yes done at the hospital; Yes done at a different hospital; Not Done; Unknown. Custom | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 8. Surgery.date | |||||||
| Definition | Date of the surgery for primary tumor with or without neck surgery | ||||||
| Short | Date of surgery | ||||||
| Control | 1..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 10. Surgery.intention | |||||||
| Definition | Palliative: surgery performed with the intent of improving quality of life or relieving symptoms caused by advanced disease. Curative: surgery performed with the intend of oncologic cure, regardless of its result (R0 / R1/R2) | ||||||
| Short | Surgery intention | ||||||
| Comments | Palliative; Curative; Unknown Palliative - 4179711 Curative procedure intent - 4162591 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 12. Surgery.typeOfApproach | |||||||
| Definition | Describes the approach to tumor resection whether it includes skin incision (extenal or open ), or it 's aproached through a natural orifice (Transnasal/transorbital/transoral) or if the approach combines two or more of the previous ones | ||||||
| Short | Type of surgical approach on Tumour | ||||||
| Comments | endoscopic?. External/Open - 4236080 Transnasal - 4050374 Transorbital - 4044897 Transoral - 4038679 Craniofacial - 4333339 Combined - Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 14. Surgery.marginsAfterSurgery | |||||||
| Definition | The R0 (?no residual rumor?) category applies only to cases in which residual tumor cannot be detected by conventional diagnostic methods. A more exact definition would read ?no detectable residual tumor.?This category corresponds to surgical resection for cure. The R1 category is reserved exclusively for cases in which residual tumor is found by histologic examination. This category may apply to biopsy sampling of the regional tissue at the site of resection or of a distant site at the time of surgery. It also applies to microscopic examination of the resection margins of the surgical resection specimen by the pathologist. R2 applies to cases with macroscopically visible residual tumor that is detected either clinically or pathologically. | ||||||
| Short | Margins after surgery | ||||||
| Comments | R0 (microscopic negative); R1 (microscopic positive); R2 (macroscopic positive); Unknown R0: No residual tumor - 1634643 R1: Microscopic residual tumor - 1633801 R2: Macroscopic residual tumor - 1634484 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 16. Surgery.tumorRupture | |||||||
| Definition | Tumor rupture Yes/No | ||||||
| Short | Tumor rupture | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 18. Surgery.specimenMitoticCount | |||||||
| Definition | Surgical specimen Mitotic count | ||||||
| Short | Surgical specimen Mitotic count | ||||||
| Control | 1..1 | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 20. Surgery.specimenGradingOnlyInUntreatedTumours | |||||||
| Definition | Surgical specimen grading only in untreated tumours | ||||||
| Short | Surgical specimen grading only in untreated tumours | ||||||
| Comments | FNCLCC : 1, 2, 3, unknown, not applicable - Other classification system: high/low Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 22. Surgery.isolatedLimbPerfusion | |||||||
| Definition | Isolated Limb perfusion | ||||||
| Short | Isolated Limb perfusion | ||||||
| Comments | Yes/No Isolated limb perfusion - 4019656 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 24. Surgery.reconstruction | |||||||
| Definition | Local flap / regional pedicled flap / free flap | ||||||
| Short | Reconstruction | ||||||
| Comments | Yes, no, unknown Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 26. Surgery.neckSurgery | |||||||
| Definition | Describes whether a surgical procedure to treat and address the neck was performed or not. | ||||||
| Short | Neck surgery | ||||||
| Comments | Yes; No; Unknown. Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 28. Surgery.dateOfNeckSurgey | |||||||
| Definition | Date of the surgery on the neck | ||||||
| Short | Date of Neck surgey | ||||||
| Control | 0..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 30. Surgery.lateralityOfTheDissection | |||||||
| Definition | Describes laterality of the neck surgical procedure: Ipsilateral when only the neck ipsilateral to the tumor has been treated Contralateral when only the neck contralateral to the tumor has been treated Bilateral: when both sides of the neck have been treated | ||||||
| Short | Laterality of the dissection | ||||||
| Comments | Ipsilateral; Bilateral; Controlateral; Unknown. Ipsilateral - 4112106 Bilateral Sampling - 4117496 Controlateral - 4112107 Unknown - 4129922 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 32. Surgery.surgeryOnM | |||||||
| Definition | Describes whether surgery is performed to treat the Metastasis | ||||||
| Short | Surgery on M | ||||||
| Comments | Yes; No; Unknown. Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 34. Surgery.dateOfSurgeryOnM | |||||||
| Definition | Date of the surgery on the metastasis | ||||||
| Short | Date of surgery on M | ||||||
| Control | 0..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 36. Surgery.siteOnMetastasis | |||||||
| Definition | Describes if site of surgery on metastasis is soft tissue | ||||||
| Short | Site of surgery on metastasis | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 38. Surgery.siteOnMetastasis.softTissue | |||||||
| Definition | Describes if site of surgery on metastasis is soft tissue | ||||||
| Short | Site of surgery on metastasis_soft tissue | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 40. Surgery.siteOnMetastasis.distantLymphNodes | |||||||
| Definition | Describes if site of surgery on metastasis is dystan lymph node | ||||||
| Short | Site of surgery on metastasis_distant lymph nodes | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 42. Surgery.siteOnMetastasis.lung | |||||||
| Definition | Describes if site of surgery on metastasis is lung | ||||||
| Short | Site of surgery on metastasis_lung | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 44. Surgery.siteOnMetastasis.bone | |||||||
| Definition | Describes if site of surgery on metastasis is bone | ||||||
| Short | Site of surgery on metastasis_bone | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 46. Surgery.siteOnMetastasis.liver | |||||||
| Definition | Describes if site of surgery on metastasis is liver | ||||||
| Short | Site of surgery on metastasis_liver | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 48. Surgery.siteOnMetastasis.pleura | |||||||
| Definition | Describes if site of surgery on metastasis is pleura | ||||||
| Short | Site of surgery on metastasis_pleura | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 50. Surgery.siteOnMetastasis.peritoneum | |||||||
| Definition | Describes if site of surgery on metastasis is peritoneum | ||||||
| Short | Site of surgery on metastasis_peritoneum | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 52. Surgery.siteOnMetastasis.brain | |||||||
| Definition | Describes if site of surgery on metastasis is brain | ||||||
| Short | Site of surgery on metastasis_brain | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 54. Surgery.siteOnMetastasis.otherViscera | |||||||
| Definition | Describes if site of surgery on metastasis is other viscera | ||||||
| Short | Site of surgery on metastasis_other viscera | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 56. Surgery.siteOnMetastasis.unknown | |||||||
| Definition | Describes if site of surgery on metastasis is unknown | ||||||
| Short | Site of surgery on metastasis_unknown | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 58. Surgery.surgicalComplications | |||||||
| Definition | Describes presence and grade of complications after a surgical procedure, | ||||||
| Short | Surgical complications (Clavien-Dindo Classification) | ||||||
| Comments | No complication; Grade I-V; unknown. No complication - 4188540 Clavien-Dindo complication scale: Grade I - 715974 Clavien-Dindo complication scale: Grade II - 715975 Clavien-Dindo complication scale: Grade III - 715976 Clavien-Dindo complication scale: Grade IIIA - 715977 Clavien-Dindo complication scale: Grade IIIB - 715978 Clavien-Dindo complication scale: Grade IV - 715979 Clavien-Dindo complication scale: Grade IVA - 715980 Clavien-Dindo complication scale: Grade IVB - 715981 Clavien-Dindo complication scale: Grade V - 715982 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
Guidance on how to interpret the contents of this table can be found here
| 0. Surgery | |||||||
| Definition | Surgery | ||||||
| Short | Surgery | ||||||
| Control | 0..* | ||||||
| Is Modifier | false | ||||||
| Logical Model | Instances of this logical model are not marked to be the target of a Reference | ||||||
| 2. Surgery.episodeEvent | |||||||
| Definition | EpisodeEvent element containing the data regarding the patient's cancer | ||||||
| Short | Episode Event reference | ||||||
| Control | 1..1 | ||||||
| Type | http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/EpisodeEvent | ||||||
| Obligations |
| ||||||
| 4. Surgery.type | |||||||
| Definition | Primary surgery/re-excision (check with unplanned or excisional biopsy) | ||||||
| Short | Surgery type | ||||||
| Comments | Primary surgery/re-excision (check with unplanned or excisional biopsy) Surgical procedure - 4301351 Local excision - 4315400 Amputation - 4217482 Limb operation - 4181193 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 6. Surgery.hospital | |||||||
| Definition | Whether or not a surgical procedure was performed and whether it was performed at the registering hospital or another hospital. Diagnostic procedures (biopsy) are not included. | ||||||
| Short | Surgery Hospital | ||||||
| Comments | Yes done at the hospital; Yes done at a different hospital; Not Done; Unknown. Custom | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 8. Surgery.date | |||||||
| Definition | Date of the surgery for primary tumor with or without neck surgery | ||||||
| Short | Date of surgery | ||||||
| Control | 1..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 10. Surgery.intention | |||||||
| Definition | Palliative: surgery performed with the intent of improving quality of life or relieving symptoms caused by advanced disease. Curative: surgery performed with the intend of oncologic cure, regardless of its result (R0 / R1/R2) | ||||||
| Short | Surgery intention | ||||||
| Comments | Palliative; Curative; Unknown Palliative - 4179711 Curative procedure intent - 4162591 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 12. Surgery.typeOfApproach | |||||||
| Definition | Describes the approach to tumor resection whether it includes skin incision (extenal or open ), or it 's aproached through a natural orifice (Transnasal/transorbital/transoral) or if the approach combines two or more of the previous ones | ||||||
| Short | Type of surgical approach on Tumour | ||||||
| Comments | endoscopic?. External/Open - 4236080 Transnasal - 4050374 Transorbital - 4044897 Transoral - 4038679 Craniofacial - 4333339 Combined - Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 14. Surgery.marginsAfterSurgery | |||||||
| Definition | The R0 (?no residual rumor?) category applies only to cases in which residual tumor cannot be detected by conventional diagnostic methods. A more exact definition would read ?no detectable residual tumor.?This category corresponds to surgical resection for cure. The R1 category is reserved exclusively for cases in which residual tumor is found by histologic examination. This category may apply to biopsy sampling of the regional tissue at the site of resection or of a distant site at the time of surgery. It also applies to microscopic examination of the resection margins of the surgical resection specimen by the pathologist. R2 applies to cases with macroscopically visible residual tumor that is detected either clinically or pathologically. | ||||||
| Short | Margins after surgery | ||||||
| Comments | R0 (microscopic negative); R1 (microscopic positive); R2 (macroscopic positive); Unknown R0: No residual tumor - 1634643 R1: Microscopic residual tumor - 1633801 R2: Macroscopic residual tumor - 1634484 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 16. Surgery.tumorRupture | |||||||
| Definition | Tumor rupture Yes/No | ||||||
| Short | Tumor rupture | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 18. Surgery.specimenMitoticCount | |||||||
| Definition | Surgical specimen Mitotic count | ||||||
| Short | Surgical specimen Mitotic count | ||||||
| Control | 1..1 | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 20. Surgery.specimenGradingOnlyInUntreatedTumours | |||||||
| Definition | Surgical specimen grading only in untreated tumours | ||||||
| Short | Surgical specimen grading only in untreated tumours | ||||||
| Comments | FNCLCC : 1, 2, 3, unknown, not applicable - Other classification system: high/low Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 22. Surgery.isolatedLimbPerfusion | |||||||
| Definition | Isolated Limb perfusion | ||||||
| Short | Isolated Limb perfusion | ||||||
| Comments | Yes/No Isolated limb perfusion - 4019656 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 24. Surgery.reconstruction | |||||||
| Definition | Local flap / regional pedicled flap / free flap | ||||||
| Short | Reconstruction | ||||||
| Comments | Yes, no, unknown Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 26. Surgery.neckSurgery | |||||||
| Definition | Describes whether a surgical procedure to treat and address the neck was performed or not. | ||||||
| Short | Neck surgery | ||||||
| Comments | Yes; No; Unknown. Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 28. Surgery.dateOfNeckSurgey | |||||||
| Definition | Date of the surgery on the neck | ||||||
| Short | Date of Neck surgey | ||||||
| Control | 0..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 30. Surgery.lateralityOfTheDissection | |||||||
| Definition | Describes laterality of the neck surgical procedure: Ipsilateral when only the neck ipsilateral to the tumor has been treated Contralateral when only the neck contralateral to the tumor has been treated Bilateral: when both sides of the neck have been treated | ||||||
| Short | Laterality of the dissection | ||||||
| Comments | Ipsilateral; Bilateral; Controlateral; Unknown. Ipsilateral - 4112106 Bilateral Sampling - 4117496 Controlateral - 4112107 Unknown - 4129922 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 32. Surgery.surgeryOnM | |||||||
| Definition | Describes whether surgery is performed to treat the Metastasis | ||||||
| Short | Surgery on M | ||||||
| Comments | Yes; No; Unknown. Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 34. Surgery.dateOfSurgeryOnM | |||||||
| Definition | Date of the surgery on the metastasis | ||||||
| Short | Date of surgery on M | ||||||
| Control | 0..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 36. Surgery.siteOnMetastasis | |||||||
| Definition | Describes if site of surgery on metastasis is soft tissue | ||||||
| Short | Site of surgery on metastasis | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||||
| 38. Surgery.siteOnMetastasis.softTissue | |||||||
| Definition | Describes if site of surgery on metastasis is soft tissue | ||||||
| Short | Site of surgery on metastasis_soft tissue | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 40. Surgery.siteOnMetastasis.distantLymphNodes | |||||||
| Definition | Describes if site of surgery on metastasis is dystan lymph node | ||||||
| Short | Site of surgery on metastasis_distant lymph nodes | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 42. Surgery.siteOnMetastasis.lung | |||||||
| Definition | Describes if site of surgery on metastasis is lung | ||||||
| Short | Site of surgery on metastasis_lung | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 44. Surgery.siteOnMetastasis.bone | |||||||
| Definition | Describes if site of surgery on metastasis is bone | ||||||
| Short | Site of surgery on metastasis_bone | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 46. Surgery.siteOnMetastasis.liver | |||||||
| Definition | Describes if site of surgery on metastasis is liver | ||||||
| Short | Site of surgery on metastasis_liver | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 48. Surgery.siteOnMetastasis.pleura | |||||||
| Definition | Describes if site of surgery on metastasis is pleura | ||||||
| Short | Site of surgery on metastasis_pleura | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 50. Surgery.siteOnMetastasis.peritoneum | |||||||
| Definition | Describes if site of surgery on metastasis is peritoneum | ||||||
| Short | Site of surgery on metastasis_peritoneum | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 52. Surgery.siteOnMetastasis.brain | |||||||
| Definition | Describes if site of surgery on metastasis is brain | ||||||
| Short | Site of surgery on metastasis_brain | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 54. Surgery.siteOnMetastasis.otherViscera | |||||||
| Definition | Describes if site of surgery on metastasis is other viscera | ||||||
| Short | Site of surgery on metastasis_other viscera | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 56. Surgery.siteOnMetastasis.unknown | |||||||
| Definition | Describes if site of surgery on metastasis is unknown | ||||||
| Short | Site of surgery on metastasis_unknown | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 58. Surgery.surgicalComplications | |||||||
| Definition | Describes presence and grade of complications after a surgical procedure, | ||||||
| Short | Surgical complications (Clavien-Dindo Classification) | ||||||
| Comments | No complication; Grade I-V; unknown. No complication - 4188540 Clavien-Dindo complication scale: Grade I - 715974 Clavien-Dindo complication scale: Grade II - 715975 Clavien-Dindo complication scale: Grade III - 715976 Clavien-Dindo complication scale: Grade IIIA - 715977 Clavien-Dindo complication scale: Grade IIIB - 715978 Clavien-Dindo complication scale: Grade IV - 715979 Clavien-Dindo complication scale: Grade IVA - 715980 Clavien-Dindo complication scale: Grade IVB - 715981 Clavien-Dindo complication scale: Grade V - 715982 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
Guidance on how to interpret the contents of this table can be found here
| 0. Surgery | |||||||
| Definition | Surgery | ||||||
| Short | Surgery | ||||||
| Control | 0..* | ||||||
| Is Modifier | false | ||||||
| Logical Model | Instances of this logical model are not marked to be the target of a Reference | ||||||
| 2. Surgery.episodeEvent | |||||||
| Definition | EpisodeEvent element containing the data regarding the patient's cancer | ||||||
| Short | Episode Event reference | ||||||
| Control | 1..1 | ||||||
| Type | http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/EpisodeEvent | ||||||
| Obligations |
| ||||||
| 4. Surgery.type | |||||||
| Definition | Primary surgery/re-excision (check with unplanned or excisional biopsy) | ||||||
| Short | Surgery type | ||||||
| Comments | Primary surgery/re-excision (check with unplanned or excisional biopsy) Surgical procedure - 4301351 Local excision - 4315400 Amputation - 4217482 Limb operation - 4181193 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 6. Surgery.hospital | |||||||
| Definition | Whether or not a surgical procedure was performed and whether it was performed at the registering hospital or another hospital. Diagnostic procedures (biopsy) are not included. | ||||||
| Short | Surgery Hospital | ||||||
| Comments | Yes done at the hospital; Yes done at a different hospital; Not Done; Unknown. Custom | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 8. Surgery.date | |||||||
| Definition | Date of the surgery for primary tumor with or without neck surgery | ||||||
| Short | Date of surgery | ||||||
| Control | 1..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 10. Surgery.intention | |||||||
| Definition | Palliative: surgery performed with the intent of improving quality of life or relieving symptoms caused by advanced disease. Curative: surgery performed with the intend of oncologic cure, regardless of its result (R0 / R1/R2) | ||||||
| Short | Surgery intention | ||||||
| Comments | Palliative; Curative; Unknown Palliative - 4179711 Curative procedure intent - 4162591 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 12. Surgery.typeOfApproach | |||||||
| Definition | Describes the approach to tumor resection whether it includes skin incision (extenal or open ), or it 's aproached through a natural orifice (Transnasal/transorbital/transoral) or if the approach combines two or more of the previous ones | ||||||
| Short | Type of surgical approach on Tumour | ||||||
| Comments | endoscopic?. External/Open - 4236080 Transnasal - 4050374 Transorbital - 4044897 Transoral - 4038679 Craniofacial - 4333339 Combined - Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 14. Surgery.marginsAfterSurgery | |||||||
| Definition | The R0 (?no residual rumor?) category applies only to cases in which residual tumor cannot be detected by conventional diagnostic methods. A more exact definition would read ?no detectable residual tumor.?This category corresponds to surgical resection for cure. The R1 category is reserved exclusively for cases in which residual tumor is found by histologic examination. This category may apply to biopsy sampling of the regional tissue at the site of resection or of a distant site at the time of surgery. It also applies to microscopic examination of the resection margins of the surgical resection specimen by the pathologist. R2 applies to cases with macroscopically visible residual tumor that is detected either clinically or pathologically. | ||||||
| Short | Margins after surgery | ||||||
| Comments | R0 (microscopic negative); R1 (microscopic positive); R2 (macroscopic positive); Unknown R0: No residual tumor - 1634643 R1: Microscopic residual tumor - 1633801 R2: Macroscopic residual tumor - 1634484 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 16. Surgery.tumorRupture | |||||||
| Definition | Tumor rupture Yes/No | ||||||
| Short | Tumor rupture | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 18. Surgery.specimenMitoticCount | |||||||
| Definition | Surgical specimen Mitotic count | ||||||
| Short | Surgical specimen Mitotic count | ||||||
| Control | 1..1 | ||||||
| Type | Quantity | ||||||
| Obligations |
| ||||||
| 20. Surgery.specimenGradingOnlyInUntreatedTumours | |||||||
| Definition | Surgical specimen grading only in untreated tumours | ||||||
| Short | Surgical specimen grading only in untreated tumours | ||||||
| Comments | FNCLCC : 1, 2, 3, unknown, not applicable - Other classification system: high/low Grade-1 - 1634371 Grade-2 - 1634752 Grade-3 - 1633749 Grade-H - 1635587 Grade-L - 1634085 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 22. Surgery.isolatedLimbPerfusion | |||||||
| Definition | Isolated Limb perfusion | ||||||
| Short | Isolated Limb perfusion | ||||||
| Comments | Yes/No Isolated limb perfusion - 4019656 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 24. Surgery.reconstruction | |||||||
| Definition | Local flap / regional pedicled flap / free flap | ||||||
| Short | Reconstruction | ||||||
| Comments | Yes, no, unknown Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 26. Surgery.neckSurgery | |||||||
| Definition | Describes whether a surgical procedure to treat and address the neck was performed or not. | ||||||
| Short | Neck surgery | ||||||
| Comments | Yes; No; Unknown. Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 28. Surgery.dateOfNeckSurgey | |||||||
| Definition | Date of the surgery on the neck | ||||||
| Short | Date of Neck surgey | ||||||
| Control | 0..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 30. Surgery.lateralityOfTheDissection | |||||||
| Definition | Describes laterality of the neck surgical procedure: Ipsilateral when only the neck ipsilateral to the tumor has been treated Contralateral when only the neck contralateral to the tumor has been treated Bilateral: when both sides of the neck have been treated | ||||||
| Short | Laterality of the dissection | ||||||
| Comments | Ipsilateral; Bilateral; Controlateral; Unknown. Ipsilateral - 4112106 Bilateral Sampling - 4117496 Controlateral - 4112107 Unknown - 4129922 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 32. Surgery.surgeryOnM | |||||||
| Definition | Describes whether surgery is performed to treat the Metastasis | ||||||
| Short | Surgery on M | ||||||
| Comments | Yes; No; Unknown. Yes - 4188539 No - 4188540 Unknown - 4129922 | ||||||
| Control | 0..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
| 34. Surgery.dateOfSurgeryOnM | |||||||
| Definition | Date of the surgery on the metastasis | ||||||
| Short | Date of surgery on M | ||||||
| Control | 0..1 | ||||||
| Type | date | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 36. Surgery.siteOnMetastasis | |||||||
| Definition | Describes if site of surgery on metastasis is soft tissue | ||||||
| Short | Site of surgery on metastasis | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||||
| 38. Surgery.siteOnMetastasis.id | |||||||
| Definition | unique id for the element within a resource (for internal references) | ||||||
| Short | xml:id (or equivalent in JSON) | ||||||
| Control | 0..1 | ||||||
| Type | string | ||||||
| Is Modifier | false | ||||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||||
| Summary | false | ||||||
| 40. Surgery.siteOnMetastasis.extension | |||||||
| Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||||
| Short | Additional content defined by implementations | ||||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||||
| Control | 0..* | ||||||
| Type | Extension | ||||||
| Is Modifier | false | ||||||
| Summary | false | ||||||
| Alternate Names | extensions, user content | ||||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) | ||||||
| 42. Surgery.siteOnMetastasis.value | |||||||
| Definition | The actual value | ||||||
| Short | Primitive value for boolean | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Is Modifier | false | ||||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||||
| Summary | false | ||||||
| 44. Surgery.siteOnMetastasis.softTissue | |||||||
| Definition | Describes if site of surgery on metastasis is soft tissue | ||||||
| Short | Site of surgery on metastasis_soft tissue | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 46. Surgery.siteOnMetastasis.distantLymphNodes | |||||||
| Definition | Describes if site of surgery on metastasis is dystan lymph node | ||||||
| Short | Site of surgery on metastasis_distant lymph nodes | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 48. Surgery.siteOnMetastasis.lung | |||||||
| Definition | Describes if site of surgery on metastasis is lung | ||||||
| Short | Site of surgery on metastasis_lung | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 50. Surgery.siteOnMetastasis.bone | |||||||
| Definition | Describes if site of surgery on metastasis is bone | ||||||
| Short | Site of surgery on metastasis_bone | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 52. Surgery.siteOnMetastasis.liver | |||||||
| Definition | Describes if site of surgery on metastasis is liver | ||||||
| Short | Site of surgery on metastasis_liver | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 54. Surgery.siteOnMetastasis.pleura | |||||||
| Definition | Describes if site of surgery on metastasis is pleura | ||||||
| Short | Site of surgery on metastasis_pleura | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 56. Surgery.siteOnMetastasis.peritoneum | |||||||
| Definition | Describes if site of surgery on metastasis is peritoneum | ||||||
| Short | Site of surgery on metastasis_peritoneum | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 58. Surgery.siteOnMetastasis.brain | |||||||
| Definition | Describes if site of surgery on metastasis is brain | ||||||
| Short | Site of surgery on metastasis_brain | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 60. Surgery.siteOnMetastasis.otherViscera | |||||||
| Definition | Describes if site of surgery on metastasis is other viscera | ||||||
| Short | Site of surgery on metastasis_other viscera | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 62. Surgery.siteOnMetastasis.unknown | |||||||
| Definition | Describes if site of surgery on metastasis is unknown | ||||||
| Short | Site of surgery on metastasis_unknown | ||||||
| Control | 0..1 | ||||||
| Type | boolean | ||||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||||
| Obligations |
| ||||||
| 64. Surgery.surgicalComplications | |||||||
| Definition | Describes presence and grade of complications after a surgical procedure, | ||||||
| Short | Surgical complications (Clavien-Dindo Classification) | ||||||
| Comments | No complication; Grade I-V; unknown. No complication - 4188540 Clavien-Dindo complication scale: Grade I - 715974 Clavien-Dindo complication scale: Grade II - 715975 Clavien-Dindo complication scale: Grade III - 715976 Clavien-Dindo complication scale: Grade IIIA - 715977 Clavien-Dindo complication scale: Grade IIIB - 715978 Clavien-Dindo complication scale: Grade IV - 715979 Clavien-Dindo complication scale: Grade IVA - 715980 Clavien-Dindo complication scale: Grade IVB - 715981 Clavien-Dindo complication scale: Grade V - 715982 | ||||||
| Control | 1..1 | ||||||
| Type | CodeableConcept | ||||||
| Obligations |
| ||||||
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.
