IDEA4RC FHIR Implementation Guide
0.1.0 - CI Build
150
IDEA4RC FHIR Implementation Guide
0.1.0 - CI Build
150
IDEA4RC FHIR Implementation Guide, published by IDEA4RC Project. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/idea4rc/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.eu/fhir/ig/idea4rc/StructureDefinition/Surgery | Version: 0.1.0 | |||
| Draft as of 2025-07-25 | Computable Name: SurgeryI4RC | |||
Surgery Maturity Level: 0 Draft
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
  Surgery |
0..* | Base | Surgery | |||||||
  diagnosisReference |
O | 1..* | Diagnosis | Diagnosis reference (M)
| ||||||
| episodeEventReference |
O | 1..* | EpisodeEvent | Episode Event reference (M)
| ||||||
 surgeryType |
O | 1..* | CodeableConcept | Surgery type (M)
| ||||||
 surgeryHospital |
O | 1..* | string | Surgery Hospital (M)
| ||||||
| dateOfSurgery |
O | 1..* | date | Date of surgery (M)
| ||||||
| surgeryIntention |
O | 0..* | CodeableConcept | Surgery intention (O)
| ||||||
| typeOfSurgicalApproachOnTumour |
O | 1..* | CodeableConcept | Type of surgical approach on Tumour (M)
| ||||||
| marginsAfterSurgery |
O | 1..* | CodeableConcept | Margins after surgery (M)
| ||||||
| tumorRupture |
O | 1..* | boolean | Tumor rupture (M)
| ||||||
| extraNodalExtension |
O | 1..* | CodeableConcept | Extra-nodal extension (rEne) (M)
| ||||||
| surgicalSpecimenMitoticCount |
O | 1..* | Quantity | Surgical specimen Mitotic count (M)
| ||||||
| surgicalSpecimenGradingOnlyInUntreatedTumours |
O | 1..* | CodeableConcept | Surgical specimen grading only in untreated tumours (M)
| ||||||
| reconstruction |
O | 1..* | boolean | Reconstruction (M)
| ||||||
| neckSurgery |
O | 1..* | boolean | Neck surgery (M)
| ||||||
| dateOfNeckSurgery |
O | 1..* | date | Date of Neck surgery (M)
| ||||||
| lateralityOfTheDissection |
O | 1..* | CodeableConcept | Laterality of the dissection (M)
| ||||||
| surgeryOnM |
O | 1..* | boolean | Surgery on M (M)
| ||||||
| dateOfSurgeryOnM |
O | 1..* | date | Date of surgery on M (M)
| ||||||
 siteOfSurgeryOnMetastasis |
O | 0..* | BackboneElement | Site of surgery on metastasis
| ||||||
 @id |
0..1 | string | Unique id for inter-element referencing | |||||||
 extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| softTissue |
O | 0..* | boolean | Site of surgery on metastasis_soft tissue (O)
| ||||||
| distantLymphNodes |
O | 0..* | boolean | Site of surgery on metastasis_distant lymph nodes (O)
| ||||||
| lung |
O | 0..* | boolean | Site of surgery on metastasis_lung (O)
| ||||||
| bone |
O | 0..* | boolean | Site of surgery on metastasis_bone (O)
| ||||||
| liver |
O | 0..* | boolean | Site of surgery on metastasis_liver (O)
| ||||||
| pleura |
O | 0..* | boolean | Site of surgery on metastasis_pleura (O)
| ||||||
| peritoneum |
O | 0..* | boolean | Site of surgery on metastasis_peritoneum (O)
| ||||||
| brain |
O | 0..* | boolean | Site of surgery on metastasis_brain (O)
| ||||||
| otherViscera |
O | 0..* | boolean | Site of surgery on metastasis_other viscera (O)
| ||||||
 unknown |
O | 0..* | boolean | Site of surgery on metastasis_unknown (O)
| ||||||
| surgicalComplications |
O | 1..* | CodeableConcept | Surgical complications (Clavien-Dindo Classification) (M)
| ||||||
| Documentation for this format | ||||||||||
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Base
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Surgery |
0..* | Base | Surgery | |||||||
| diagnosisReference |
O | 1..* | Diagnosis | Diagnosis reference (M)
| ||||||
| episodeEventReference |
O | 1..* | EpisodeEvent | Episode Event reference (M)
| ||||||
| surgeryType |
O | 1..* | CodeableConcept | Surgery type (M)
| ||||||
| surgeryHospital |
O | 1..* | string | Surgery Hospital (M)
| ||||||
| dateOfSurgery |
O | 1..* | date | Date of surgery (M)
| ||||||
| surgeryIntention |
O | 0..* | CodeableConcept | Surgery intention (O)
| ||||||
| typeOfSurgicalApproachOnTumour |
O | 1..* | CodeableConcept | Type of surgical approach on Tumour (M)
| ||||||
| marginsAfterSurgery |
O | 1..* | CodeableConcept | Margins after surgery (M)
| ||||||
| tumorRupture |
O | 1..* | boolean | Tumor rupture (M)
| ||||||
| extraNodalExtension |
O | 1..* | CodeableConcept | Extra-nodal extension (rEne) (M)
| ||||||
| surgicalSpecimenMitoticCount |
O | 1..* | Quantity | Surgical specimen Mitotic count (M)
| ||||||
| surgicalSpecimenGradingOnlyInUntreatedTumours |
O | 1..* | CodeableConcept | Surgical specimen grading only in untreated tumours (M)
| ||||||
| reconstruction |
O | 1..* | boolean | Reconstruction (M)
| ||||||
| neckSurgery |
O | 1..* | boolean | Neck surgery (M)
| ||||||
| dateOfNeckSurgery |
O | 1..* | date | Date of Neck surgery (M)
| ||||||
| lateralityOfTheDissection |
O | 1..* | CodeableConcept | Laterality of the dissection (M)
| ||||||
| surgeryOnM |
O | 1..* | boolean | Surgery on M (M)
| ||||||
| dateOfSurgeryOnM |
O | 1..* | date | Date of surgery on M (M)
| ||||||
| siteOfSurgeryOnMetastasis |
O | 0..* | BackboneElement | Site of surgery on metastasis
| ||||||
| softTissue |
O | 0..* | boolean | Site of surgery on metastasis_soft tissue (O)
| ||||||
| distantLymphNodes |
O | 0..* | boolean | Site of surgery on metastasis_distant lymph nodes (O)
| ||||||
| lung |
O | 0..* | boolean | Site of surgery on metastasis_lung (O)
| ||||||
| bone |
O | 0..* | boolean | Site of surgery on metastasis_bone (O)
| ||||||
| liver |
O | 0..* | boolean | Site of surgery on metastasis_liver (O)
| ||||||
| pleura |
O | 0..* | boolean | Site of surgery on metastasis_pleura (O)
| ||||||
| peritoneum |
O | 0..* | boolean | Site of surgery on metastasis_peritoneum (O)
| ||||||
| brain |
O | 0..* | boolean | Site of surgery on metastasis_brain (O)
| ||||||
| otherViscera |
O | 0..* | boolean | Site of surgery on metastasis_other viscera (O)
| ||||||
| unknown |
O | 0..* | boolean | Site of surgery on metastasis_unknown (O)
| ||||||
| surgicalComplications |
O | 1..* | CodeableConcept | Surgical complications (Clavien-Dindo Classification) (M)
| ||||||
| Documentation for this format | ||||||||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Surgery |
0..* | Base | Surgery | |||||||
| diagnosisReference |
O | 1..* | Diagnosis | Diagnosis reference (M)
| ||||||
| episodeEventReference |
O | 1..* | EpisodeEvent | Episode Event reference (M)
| ||||||
| surgeryType |
O | 1..* | CodeableConcept | Surgery type (M)
| ||||||
| surgeryHospital |
O | 1..* | string | Surgery Hospital (M)
| ||||||
| dateOfSurgery |
O | 1..* | date | Date of surgery (M)
| ||||||
| surgeryIntention |
O | 0..* | CodeableConcept | Surgery intention (O)
| ||||||
| typeOfSurgicalApproachOnTumour |
O | 1..* | CodeableConcept | Type of surgical approach on Tumour (M)
| ||||||
| marginsAfterSurgery |
O | 1..* | CodeableConcept | Margins after surgery (M)
| ||||||
| tumorRupture |
O | 1..* | boolean | Tumor rupture (M)
| ||||||
| extraNodalExtension |
O | 1..* | CodeableConcept | Extra-nodal extension (rEne) (M)
| ||||||
| surgicalSpecimenMitoticCount |
O | 1..* | Quantity | Surgical specimen Mitotic count (M)
| ||||||
| surgicalSpecimenGradingOnlyInUntreatedTumours |
O | 1..* | CodeableConcept | Surgical specimen grading only in untreated tumours (M)
| ||||||
| reconstruction |
O | 1..* | boolean | Reconstruction (M)
| ||||||
| neckSurgery |
O | 1..* | boolean | Neck surgery (M)
| ||||||
| dateOfNeckSurgery |
O | 1..* | date | Date of Neck surgery (M)
| ||||||
| lateralityOfTheDissection |
O | 1..* | CodeableConcept | Laterality of the dissection (M)
| ||||||
| surgeryOnM |
O | 1..* | boolean | Surgery on M (M)
| ||||||
| dateOfSurgeryOnM |
O | 1..* | date | Date of surgery on M (M)
| ||||||
| siteOfSurgeryOnMetastasis |
O | 0..* | BackboneElement | Site of surgery on metastasis
| ||||||
| @id |
0..1 | string | Unique id for inter-element referencing | |||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| softTissue |
O | 0..* | boolean | Site of surgery on metastasis_soft tissue (O)
| ||||||
| distantLymphNodes |
O | 0..* | boolean | Site of surgery on metastasis_distant lymph nodes (O)
| ||||||
| lung |
O | 0..* | boolean | Site of surgery on metastasis_lung (O)
| ||||||
| bone |
O | 0..* | boolean | Site of surgery on metastasis_bone (O)
| ||||||
| liver |
O | 0..* | boolean | Site of surgery on metastasis_liver (O)
| ||||||
| pleura |
O | 0..* | boolean | Site of surgery on metastasis_pleura (O)
| ||||||
| peritoneum |
O | 0..* | boolean | Site of surgery on metastasis_peritoneum (O)
| ||||||
| brain |
O | 0..* | boolean | Site of surgery on metastasis_brain (O)
| ||||||
| otherViscera |
O | 0..* | boolean | Site of surgery on metastasis_other viscera (O)
| ||||||
| unknown |
O | 0..* | boolean | Site of surgery on metastasis_unknown (O)
| ||||||
| surgicalComplications |
O | 1..* | CodeableConcept | Surgical complications (Clavien-Dindo Classification) (M)
| ||||||
| Documentation for this format | ||||||||||
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Base
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Surgery |
0..* | Base | Surgery | |||||||
| diagnosisReference |
O | 1..* | Diagnosis | Diagnosis reference (M)
| ||||||
| episodeEventReference |
O | 1..* | EpisodeEvent | Episode Event reference (M)
| ||||||
| surgeryType |
O | 1..* | CodeableConcept | Surgery type (M)
| ||||||
| surgeryHospital |
O | 1..* | string | Surgery Hospital (M)
| ||||||
| dateOfSurgery |
O | 1..* | date | Date of surgery (M)
| ||||||
| surgeryIntention |
O | 0..* | CodeableConcept | Surgery intention (O)
| ||||||
| typeOfSurgicalApproachOnTumour |
O | 1..* | CodeableConcept | Type of surgical approach on Tumour (M)
| ||||||
| marginsAfterSurgery |
O | 1..* | CodeableConcept | Margins after surgery (M)
| ||||||
| tumorRupture |
O | 1..* | boolean | Tumor rupture (M)
| ||||||
| extraNodalExtension |
O | 1..* | CodeableConcept | Extra-nodal extension (rEne) (M)
| ||||||
| surgicalSpecimenMitoticCount |
O | 1..* | Quantity | Surgical specimen Mitotic count (M)
| ||||||
| surgicalSpecimenGradingOnlyInUntreatedTumours |
O | 1..* | CodeableConcept | Surgical specimen grading only in untreated tumours (M)
| ||||||
| reconstruction |
O | 1..* | boolean | Reconstruction (M)
| ||||||
| neckSurgery |
O | 1..* | boolean | Neck surgery (M)
| ||||||
| dateOfNeckSurgery |
O | 1..* | date | Date of Neck surgery (M)
| ||||||
| lateralityOfTheDissection |
O | 1..* | CodeableConcept | Laterality of the dissection (M)
| ||||||
| surgeryOnM |
O | 1..* | boolean | Surgery on M (M)
| ||||||
| dateOfSurgeryOnM |
O | 1..* | date | Date of surgery on M (M)
| ||||||
| siteOfSurgeryOnMetastasis |
O | 0..* | BackboneElement | Site of surgery on metastasis
| ||||||
| @id |
0..1 | string | Unique id for inter-element referencing | |||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| softTissue |
O | 0..* | boolean | Site of surgery on metastasis_soft tissue (O)
| ||||||
| distantLymphNodes |
O | 0..* | boolean | Site of surgery on metastasis_distant lymph nodes (O)
| ||||||
| lung |
O | 0..* | boolean | Site of surgery on metastasis_lung (O)
| ||||||
| bone |
O | 0..* | boolean | Site of surgery on metastasis_bone (O)
| ||||||
| liver |
O | 0..* | boolean | Site of surgery on metastasis_liver (O)
| ||||||
| pleura |
O | 0..* | boolean | Site of surgery on metastasis_pleura (O)
| ||||||
| peritoneum |
O | 0..* | boolean | Site of surgery on metastasis_peritoneum (O)
| ||||||
| brain |
O | 0..* | boolean | Site of surgery on metastasis_brain (O)
| ||||||
| otherViscera |
O | 0..* | boolean | Site of surgery on metastasis_other viscera (O)
| ||||||
| unknown |
O | 0..* | boolean | Site of surgery on metastasis_unknown (O)
| ||||||
| surgicalComplications |
O | 1..* | CodeableConcept | Surgical complications (Clavien-Dindo Classification) (M)
| ||||||
| Documentation for this format | ||||||||||
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Differential View
This structure is derived from Base
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Surgery |
0..* | Base | Surgery | |||||||
| diagnosisReference |
O | 1..* | Diagnosis | Diagnosis reference (M)
| ||||||
| episodeEventReference |
O | 1..* | EpisodeEvent | Episode Event reference (M)
| ||||||
| surgeryType |
O | 1..* | CodeableConcept | Surgery type (M)
| ||||||
| surgeryHospital |
O | 1..* | string | Surgery Hospital (M)
| ||||||
| dateOfSurgery |
O | 1..* | date | Date of surgery (M)
| ||||||
| surgeryIntention |
O | 0..* | CodeableConcept | Surgery intention (O)
| ||||||
| typeOfSurgicalApproachOnTumour |
O | 1..* | CodeableConcept | Type of surgical approach on Tumour (M)
| ||||||
| marginsAfterSurgery |
O | 1..* | CodeableConcept | Margins after surgery (M)
| ||||||
| tumorRupture |
O | 1..* | boolean | Tumor rupture (M)
| ||||||
| extraNodalExtension |
O | 1..* | CodeableConcept | Extra-nodal extension (rEne) (M)
| ||||||
| surgicalSpecimenMitoticCount |
O | 1..* | Quantity | Surgical specimen Mitotic count (M)
| ||||||
| surgicalSpecimenGradingOnlyInUntreatedTumours |
O | 1..* | CodeableConcept | Surgical specimen grading only in untreated tumours (M)
| ||||||
| reconstruction |
O | 1..* | boolean | Reconstruction (M)
| ||||||
| neckSurgery |
O | 1..* | boolean | Neck surgery (M)
| ||||||
| dateOfNeckSurgery |
O | 1..* | date | Date of Neck surgery (M)
| ||||||
| lateralityOfTheDissection |
O | 1..* | CodeableConcept | Laterality of the dissection (M)
| ||||||
| surgeryOnM |
O | 1..* | boolean | Surgery on M (M)
| ||||||
| dateOfSurgeryOnM |
O | 1..* | date | Date of surgery on M (M)
| ||||||
| siteOfSurgeryOnMetastasis |
O | 0..* | BackboneElement | Site of surgery on metastasis
| ||||||
| softTissue |
O | 0..* | boolean | Site of surgery on metastasis_soft tissue (O)
| ||||||
| distantLymphNodes |
O | 0..* | boolean | Site of surgery on metastasis_distant lymph nodes (O)
| ||||||
| lung |
O | 0..* | boolean | Site of surgery on metastasis_lung (O)
| ||||||
| bone |
O | 0..* | boolean | Site of surgery on metastasis_bone (O)
| ||||||
| liver |
O | 0..* | boolean | Site of surgery on metastasis_liver (O)
| ||||||
| pleura |
O | 0..* | boolean | Site of surgery on metastasis_pleura (O)
| ||||||
| peritoneum |
O | 0..* | boolean | Site of surgery on metastasis_peritoneum (O)
| ||||||
| brain |
O | 0..* | boolean | Site of surgery on metastasis_brain (O)
| ||||||
| otherViscera |
O | 0..* | boolean | Site of surgery on metastasis_other viscera (O)
| ||||||
| unknown |
O | 0..* | boolean | Site of surgery on metastasis_unknown (O)
| ||||||
| surgicalComplications |
O | 1..* | CodeableConcept | Surgical complications (Clavien-Dindo Classification) (M)
| ||||||
| Documentation for this format | ||||||||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Surgery |
0..* | Base | Surgery | |||||||
| diagnosisReference |
O | 1..* | Diagnosis | Diagnosis reference (M)
| ||||||
| episodeEventReference |
O | 1..* | EpisodeEvent | Episode Event reference (M)
| ||||||
| surgeryType |
O | 1..* | CodeableConcept | Surgery type (M)
| ||||||
| surgeryHospital |
O | 1..* | string | Surgery Hospital (M)
| ||||||
| dateOfSurgery |
O | 1..* | date | Date of surgery (M)
| ||||||
| surgeryIntention |
O | 0..* | CodeableConcept | Surgery intention (O)
| ||||||
| typeOfSurgicalApproachOnTumour |
O | 1..* | CodeableConcept | Type of surgical approach on Tumour (M)
| ||||||
| marginsAfterSurgery |
O | 1..* | CodeableConcept | Margins after surgery (M)
| ||||||
| tumorRupture |
O | 1..* | boolean | Tumor rupture (M)
| ||||||
| extraNodalExtension |
O | 1..* | CodeableConcept | Extra-nodal extension (rEne) (M)
| ||||||
| surgicalSpecimenMitoticCount |
O | 1..* | Quantity | Surgical specimen Mitotic count (M)
| ||||||
| surgicalSpecimenGradingOnlyInUntreatedTumours |
O | 1..* | CodeableConcept | Surgical specimen grading only in untreated tumours (M)
| ||||||
| reconstruction |
O | 1..* | boolean | Reconstruction (M)
| ||||||
| neckSurgery |
O | 1..* | boolean | Neck surgery (M)
| ||||||
| dateOfNeckSurgery |
O | 1..* | date | Date of Neck surgery (M)
| ||||||
| lateralityOfTheDissection |
O | 1..* | CodeableConcept | Laterality of the dissection (M)
| ||||||
| surgeryOnM |
O | 1..* | boolean | Surgery on M (M)
| ||||||
| dateOfSurgeryOnM |
O | 1..* | date | Date of surgery on M (M)
| ||||||
| siteOfSurgeryOnMetastasis |
O | 0..* | BackboneElement | Site of surgery on metastasis
| ||||||
| @id |
0..1 | string | Unique id for inter-element referencing | |||||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||
| softTissue |
O | 0..* | boolean | Site of surgery on metastasis_soft tissue (O)
| ||||||
| distantLymphNodes |
O | 0..* | boolean | Site of surgery on metastasis_distant lymph nodes (O)
| ||||||
| lung |
O | 0..* | boolean | Site of surgery on metastasis_lung (O)
| ||||||
| bone |
O | 0..* | boolean | Site of surgery on metastasis_bone (O)
| ||||||
| liver |
O | 0..* | boolean | Site of surgery on metastasis_liver (O)
| ||||||
| pleura |
O | 0..* | boolean | Site of surgery on metastasis_pleura (O)
| ||||||
| peritoneum |
O | 0..* | boolean | Site of surgery on metastasis_peritoneum (O)
| ||||||
| brain |
O | 0..* | boolean | Site of surgery on metastasis_brain (O)
| ||||||
| otherViscera |
O | 0..* | boolean | Site of surgery on metastasis_other viscera (O)
| ||||||
| unknown |
O | 0..* | boolean | Site of surgery on metastasis_unknown (O)
| ||||||
| surgicalComplications |
O | 1..* | CodeableConcept | Surgical complications (Clavien-Dindo Classification) (M)
| ||||||
| Documentation for this format | ||||||||||
| Id | Grade | Path(s) | Details | Requirements |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Base
IG © 2022+ IDEA4RC Project. Package hl7.eu.fhir.idea4rc#0.1.0 based on FHIR 4.0.1. Generated 2025-07-25
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.
