PanCareSurPass Project HL7 FHIR Implementation Guide
1.0.0 - release 150

PanCareSurPass Project HL7 FHIR Implementation Guide, published by PanCareSurPass Project. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-eu/pcsp/ and changes regularly. See the Directory of published versions

## Resource Profile: Procedure: Surgery

Official URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-surgery-eu-pcsp | Version: 1.0.0
Active as of 2025-10-16 | Computable Name: ProcedureSurgeryPcsp

This profile defines how to represent Procedures in FHIR for describing a set of Surgery data required by the PanCareSurPass algorithm to generate the care plan. It is used also to provide inforamtion about shunt, amputation, and other procedures

Usages:

- Use this Profile: Bundle: Survivor Passport
- Refer to this Profile: Composition: Survivor Passport and Procedure: Surgery

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.

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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:sacrifiedOrgan |  | 0..* | CodeableConcept | Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
extension:notAffectedOrgan |  | 0..* | CodeableConcept | Not affected Organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan Binding: Affected Organs (surgery) (preferred)
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Identifiers for this surgical procedure
partOf | Σ | 0..* | Reference(Procedure: Surgery) | Reference to the parent surgery procedure
status | ?!S Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown 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 Type (extensible)
subject | S Σ | 1..1 | Reference(Patient: PCSP) | 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
location | Σ | 0..1 | Reference(Location: PCSP) | Where the procedure happened
reasonReference | S Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: Affected Organs (surgery) (extensible)
Slices for extension |  |  |  | Content/Rules for all slices
extension:laterality |  | 0..1 | (Complex) | Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice |  | 0..* | BackboneElement | Implanted or removed device
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
action |  | 0..1 | CodeableConcept | Kind of change to device Binding: Surgical Actions (extensible)
manipulated |  | 1..1 | Reference(Device) | Device manipulated
usedCode |  | 0..* | CodeableConcept | Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
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 Type | 📦1.0.0 | This IG
Procedure.bodySite | Base | extensible | Affected Organs (surgery) | 📦1.0.0 | This IG
Procedure.bodySite.extension:laterality.​value[x] | Base | required | Laterality Qualifier Value Set | 📦4.0.0 | minimal Common Oncology Data Elements v4.0
Procedure.focalDevice.​action | Base | extensible | Surgical Actions | 📦1.0.0 | This IG
Procedure.usedCode | Base | extensible | Prosthesis Type | 📦1.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | A resource should have narrative for robust management | `text.`div`.exists()`
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 Procedure

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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:sacrifiedOrgan |  | 0..* | CodeableConcept | Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
extension:notAffectedOrgan |  | 0..* | CodeableConcept | Not affected Organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan Binding: Affected Organs (surgery) (preferred)
identifier |  | 0..* | Identifier | External Identifiers for this surgical procedure
partOf |  | 0..* | Reference(Procedure: Surgery) | Reference to the parent surgery procedure
status | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
category |  | 1..1 | CodeableConcept | Classification of the procedure Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003
code |  | 0..1 | CodeableConcept | Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject | S | 1..1 | Reference(Patient: PCSP) | 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
location |  | 0..1 | Reference(Location: PCSP) | Where the procedure happened
reasonReference | S | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed
bodySite |  | 0..* | CodeableConcept | Target body sites Binding: Affected Organs (surgery) (extensible)
Slices for extension |  |  |  | Content/Rules for all slices
extension:laterality |  | 0..1 | (Complex) | Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice |  | 0..* | BackboneElement | Implanted or removed device
action |  | 0..1 | CodeableConcept | Kind of change to device Binding: Surgical Actions (extensible)
manipulated |  | 1..1 | Reference(Device) | Device manipulated
usedCode |  | 0..* | CodeableConcept | Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Procedure.code | Base | extensible | Surgical Procedure Type | 📦1.0.0 | This IG
Procedure.bodySite | Base | extensible | Affected Organs (surgery) | 📦1.0.0 | This IG
Procedure.bodySite.extension:laterality.​value[x] | Base | required | Laterality Qualifier Value Set | 📦4.0.0 | minimal Common Oncology Data Elements v4.0
Procedure.focalDevice.​action | Base | extensible | Surgical Actions | 📦1.0.0 | This IG
Procedure.usedCode | Base | extensible | Prosthesis Type | 📦1.0.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Textual description of the surgical procedure 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:sacrifiedOrgan |  | 0..* | CodeableConcept | Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
extension:notAffectedOrgan |  | 0..* | CodeableConcept | Not affected Organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan Binding: Affected Organs (surgery) (preferred)
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 | ?!S Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | Σ | 0..1 | CodeableConcept | Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject | S Σ | 1..1 | Reference(Patient: PCSP) | 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: PCSP) | 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 | S Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: Affected Organs (surgery) (extensible)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:laterality |  | 0..1 | (Complex) | Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Laterality Qualifier Value Set (required)
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report |  | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure
complication |  | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail |  | 0..* | Reference(Condition) | A condition that is a result of the procedure
followUp |  | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note |  | 0..* | Annotation | Additional information about the procedure
focalDevice |  | 0..* | BackboneElement | 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: Surgical Actions (extensible)
manipulated |  | 1..1 | Reference(Device) | Device manipulated
usedReference |  | 0..* | Reference(Device | Medication | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
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 Type | 📦1.0.0 | 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 | extensible | Affected Organs (surgery) | 📦1.0.0 | This IG
Procedure.bodySite.extension:laterality.​value[x] | Base | required | Laterality Qualifier Value Set | 📦4.0.0 | minimal Common Oncology Data Elements v4.0
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | extensible | Surgical Actions | 📦1.0.0 | This IG
Procedure.usedCode | Base | extensible | Prosthesis Type | 📦1.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | A resource should have narrative for robust management | `text.`div`.exists()`
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 Procedure

Summary

Mandatory: 4 elements
Must-Support: 3 elements

Structures

This structure refers to these other structures:

- Procedure: Surgery (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-surgery-eu-pcsp)
- Patient: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Patient-eu-pcsp)
- Location: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Location-eu-pcsp)
- Condition: Primary Cancer (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Condition-primaryCancer-eu-pcsp)

Extensions

This structure refers to these extensions:

- http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan
- http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan
- http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier

Slices

This structure defines the following Slices:

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

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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:sacrifiedOrgan |  | 0..* | CodeableConcept | Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
extension:notAffectedOrgan |  | 0..* | CodeableConcept | Not affected Organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan Binding: Affected Organs (surgery) (preferred)
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | External Identifiers for this surgical procedure
partOf | Σ | 0..* | Reference(Procedure: Surgery) | Reference to the parent surgery procedure
status | ?!S Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown 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 Type (extensible)
subject | S Σ | 1..1 | Reference(Patient: PCSP) | 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
location | Σ | 0..1 | Reference(Location: PCSP) | Where the procedure happened
reasonReference | S Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: Affected Organs (surgery) (extensible)
Slices for extension |  |  |  | Content/Rules for all slices
extension:laterality |  | 0..1 | (Complex) | Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice |  | 0..* | BackboneElement | Implanted or removed device
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
action |  | 0..1 | CodeableConcept | Kind of change to device Binding: Surgical Actions (extensible)
manipulated |  | 1..1 | Reference(Device) | Device manipulated
usedCode |  | 0..* | CodeableConcept | Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
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 Type | 📦1.0.0 | This IG
Procedure.bodySite | Base | extensible | Affected Organs (surgery) | 📦1.0.0 | This IG
Procedure.bodySite.extension:laterality.​value[x] | Base | required | Laterality Qualifier Value Set | 📦4.0.0 | minimal Common Oncology Data Elements v4.0
Procedure.focalDevice.​action | Base | extensible | Surgical Actions | 📦1.0.0 | This IG
Procedure.usedCode | Base | extensible | Prosthesis Type | 📦1.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | A resource should have narrative for robust management | `text.`div`.exists()`
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 Procedure

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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:sacrifiedOrgan |  | 0..* | CodeableConcept | Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
extension:notAffectedOrgan |  | 0..* | CodeableConcept | Not affected Organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan Binding: Affected Organs (surgery) (preferred)
identifier |  | 0..* | Identifier | External Identifiers for this surgical procedure
partOf |  | 0..* | Reference(Procedure: Surgery) | Reference to the parent surgery procedure
status | S | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
category |  | 1..1 | CodeableConcept | Classification of the procedure Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003
code |  | 0..1 | CodeableConcept | Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject | S | 1..1 | Reference(Patient: PCSP) | 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
location |  | 0..1 | Reference(Location: PCSP) | Where the procedure happened
reasonReference | S | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed
bodySite |  | 0..* | CodeableConcept | Target body sites Binding: Affected Organs (surgery) (extensible)
Slices for extension |  |  |  | Content/Rules for all slices
extension:laterality |  | 0..1 | (Complex) | Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice |  | 0..* | BackboneElement | Implanted or removed device
action |  | 0..1 | CodeableConcept | Kind of change to device Binding: Surgical Actions (extensible)
manipulated |  | 1..1 | Reference(Device) | Device manipulated
usedCode |  | 0..* | CodeableConcept | Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Procedure.code | Base | extensible | Surgical Procedure Type | 📦1.0.0 | This IG
Procedure.bodySite | Base | extensible | Affected Organs (surgery) | 📦1.0.0 | This IG
Procedure.bodySite.extension:laterality.​value[x] | Base | required | Laterality Qualifier Value Set | 📦4.0.0 | minimal Common Oncology Data Elements v4.0
Procedure.focalDevice.​action | Base | extensible | Surgical Actions | 📦1.0.0 | This IG
Procedure.usedCode | Base | extensible | Prosthesis Type | 📦1.0.0 | This IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Procedure |  | 0..* | Procedure | An action that is being or was performed on a patient
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Textual description of the surgical procedure 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:sacrifiedOrgan |  | 0..* | CodeableConcept | Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
extension:notAffectedOrgan |  | 0..* | CodeableConcept | Not affected Organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan Binding: Affected Organs (surgery) (preferred)
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 | ?!S Σ | 1..1 | code | preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category | Σ | 1..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 387713003
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code | Σ | 0..1 | CodeableConcept | Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject | S Σ | 1..1 | Reference(Patient: PCSP) | 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: PCSP) | 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 | S Σ | 1..* | Reference(Condition: Primary Cancer) | The justification that the procedure was performed
bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: Affected Organs (surgery) (extensible)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:laterality |  | 0..1 | (Complex) | Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Laterality Qualifier Value Set (required)
coding | Σ | 0..* | Coding | Code defined by a terminology system
text | Σ | 0..1 | string | Plain text representation of the concept
outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report |  | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure
complication |  | 0..* | CodeableConcept | Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail |  | 0..* | Reference(Condition) | A condition that is a result of the procedure
followUp |  | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note |  | 0..* | Annotation | Additional information about the procedure
focalDevice |  | 0..* | BackboneElement | 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: Surgical Actions (extensible)
manipulated |  | 1..1 | Reference(Device) | Device manipulated
usedReference |  | 0..* | Reference(Device | Medication | Substance) | Items used during procedure
usedCode |  | 0..* | CodeableConcept | Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Procedure.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
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 Type | 📦1.0.0 | 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 | extensible | Affected Organs (surgery) | 📦1.0.0 | This IG
Procedure.bodySite.extension:laterality.​value[x] | Base | required | Laterality Qualifier Value Set | 📦4.0.0 | minimal Common Oncology Data Elements v4.0
Procedure.outcome | Base | example | Procedure Outcome Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📍4.0.1 | FHIR Std.
Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📍4.0.1 | FHIR Std.
Procedure.focalDevice.​action | Base | extensible | Surgical Actions | 📦1.0.0 | This IG
Procedure.usedCode | Base | extensible | Prosthesis Type | 📦1.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Procedure | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Procedure | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Procedure | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Procedure | A resource should have narrative for robust management | `text.`div`.exists()`
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 Procedure

Summary

Mandatory: 4 elements
Must-Support: 3 elements

Structures

This structure refers to these other structures:

- Procedure: Surgery (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-surgery-eu-pcsp)
- Patient: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Patient-eu-pcsp)
- Location: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Location-eu-pcsp)
- Condition: Primary Cancer (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Condition-primaryCancer-eu-pcsp)

Extensions

This structure refers to these extensions:

- http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan
- http://hl7.eu/fhir/ig/pcsp/StructureDefinition/procedure-notAffectedOrgan
- http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier

Slices

This structure defines the following Slices:

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

Other representations of profile: CSV, Excel, Schematron