HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE), v0.9.1

HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE), v0.9.1 FHIR Profiles - Local Development build (v0.9.1). See the Directory of published versions

CancerRelatedRadiationProcedure

Definitions for onco-core-CancerRelatedRadiationProcedure.

1. Procedure-argoprofile
Definition

A radiological treatment addressing a cancer condition. The scope of this profile has been narrowed to cancer-related procedures by constraining the ReasonReference and ReasonCode to cancer conditions.

Conformance note: If an ICD-10-PCS code is used in the code attribute, and there is a semantically equivalent SNOMED CT or CPT code, the resulting Procedure instance will not be compliant with US Core Profiles

Control0..*
Max Length0
InvariantsDefined on this element
pro-1: Reason not performed is only permitted if notPerformed indicator is true (: )
2. Procedure-argoprofile.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.

Max Length0
3. Procedure-argoprofile.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.

Control0..1
TypeMeta
Max Length0
4. Procedure-argoprofile.meta.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
5. Procedure-argoprofile.meta.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

SlicingThis element introduces a set of slices on Procedure.meta.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
6. sourcesystem
SliceNamesourcesystem
Definition

FHIR: This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. FHIM: Identifies the computer system that created the medical record. This optional field may also be used to indicate that the medical record was originally created by a different organization from the one that is currently storing or utilizing the record in that the assigning authority of the Id could be set to that originating organization. This property is optional, as some systems will assume that all records that it contains originated in that system, however it is anticipated that it will become increasingly commonplace for records from multiple systems and organizations will be comingled in order to provide a complete picture of the patient's health record.

Control0..1
TypeExtension(SourceSystem) (Extension Type: uri)
7. Procedure-argoprofile.meta.versionId
Definition

The version specific identifier, as it appears in the version portion of the URL. This values changes when the resource is created, updated, or deleted.

Control0..1
Typeid
Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

8. Procedure-argoprofile.meta.lastUpdated
Definition

When the resource last changed - e.g. when the version changed.

Control0..1
Typeinstant
Comments

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant.

9. Procedure-argoprofile.meta.profile
Definition

A list of profiles StructureDefinitions that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Control0..*
Typeuri
Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

10. Procedure-argoprofile.meta.security
Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Control0..*
BindingSecurity Labels from the Healthcare Privacy and Security Classification System.
The codes SHALL be taken from All Security Labels; other codes may be used where these codes are not suitable
TypeCoding
Comments

The security labels can be updated without changing the stated version of the resource The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

11. Procedure-argoprofile.meta.tag
Definition

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

Control0..*
BindingCodes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"
TypeCoding
Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

12. Procedure-argoprofile.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.

Control0..1
Typeuri
Is Modifiertrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.

Max Length0
13. Procedure-argoprofile.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language.
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Max Length0
14. Procedure-argoprofile.text
Definition

A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Max Length0
15. Procedure-argoprofile.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

Max Length0
16. Procedure-argoprofile.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

Max Length0
SlicingThis element introduces a set of slices on Procedure.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
17. procedurepartof
SliceNameprocedurepartof
Definition

A larger event of which this particular procedure is a component or step.

Control0..1
TypeExtension(ProcedurePartOf) (Extension Type: Reference(Procedure | MedicationAdministration | Observation))
Max Length0
18. statusreason
SliceNamestatusreason
Definition

Captures the reason for the current state of the procedure.

Control0..1
TypeExtension(StatusReason) (Extension Type: CodeableConcept)
Max Length0
19. complicationreference
SliceNamecomplicationreference
Definition

Complication following the procedure, as a reference to a Condition.

Control0..*
TypeExtension(ComplicationReference) (Extension Type: Reference(Condition))
Max Length0
20. usedcode
SliceNameusedcode
Definition

Item used during an activity, represented as a code.

Control0..*
TypeExtension(UsedCode) (Extension Type: CodeableConcept)
Max Length0
21. statementdatetime
SliceNamestatementdatetime
Definition

The point in time when the statement was created.

Control0..1
TypeExtension(StatementDateTime) (Extension Type: dateTime)
Max Length0
22. occurrencetimeorperiod
SliceNameoccurrencetimeorperiod
Definition

The point or period of time when the event takes place. Times can be precise (dateTime) or approximate (date). If a time period is used, and the start date or dateTime is missing, the start of the period is not known. If the end date or dateTime is missing, it means that the period is ongoing.

Control0..1
TypeExtension(OccurrenceTimeOrPeriod) (Extension Type: Choice of: date, dateTime, Period)
Must Supporttrue
Max Length0
23. personauthor
SliceNamepersonauthor
Definition

A human author, patient, practitioner, or related person, as opposed to an organization or device.

Control0..1
TypeExtension(PersonAuthor) (Extension Type: Reference(Patient | Practitioner | RelatedPerson))
Max Length0
24. personinformationsource
SliceNamepersoninformationsource
Definition

The person who provided the information, not necessarily the patient.

Control0..1
TypeExtension(PersonInformationSource) (Extension Type: Reference(Patient | Practitioner | RelatedPerson))
Max Length0
25. treatmentintent
SliceNametreatmentintent
Definition

The purpose of a treatment.

Control0..1
TypeExtension(TreatmentIntent) (Extension Type: CodeableConcept)
Must Supporttrue
Max Length0
26. radiationdoseperfraction
SliceNameradiationdoseperfraction
Definition

The amount of radiation administered during a single session (fraction) of radiation therapy therapy.

Control0..1
TypeExtension(RadiationDosePerFraction) (Extension Type: Quantity)
Max Length0
27. radiationfractionsdelivered
SliceNameradiationfractionsdelivered
Definition

Records the total number of treatment sessions (fractions) administered during the first course of therapy. Corresponds to LOINC 21950-2 'Number of radiation treatment' [sic].

Control0..1
TypeExtension(RadiationFractionsDelivered) (Extension Type: Quantity)
Max Length0
28. totalradiationdosedelivered
SliceNametotalradiationdosedelivered
Definition

The total amount of radiation dose delivered for the course of therapy. (source: SNOMED, ASTRO)

Control0..1
TypeExtension(TotalRadiationDoseDelivered) (Extension Type: Quantity)
Max Length0
29. terminationreason
SliceNameterminationreason
Definition

A code explaining unplanned or premature termination of a plan of treatment, course of medication, or research study.

Control0..*
TypeExtension(TerminationReason) (Extension Type: CodeableConcept)
Max Length0
30. Procedure-argoprofile.extension-terminationreason.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
31. Procedure-argoprofile.extension-terminationreason.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..0
TypeExtension
Alternate Namesextensions, user content
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.

32. Procedure-argoprofile.extension-terminationreason.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Fixed Valuehttp://mcodeinitiative.org/us/mcode/StructureDefinition/obf-TerminationReason-extension
33. Procedure-argoprofile.extension-terminationreason.val
Definition

Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list).

Control1..1
BindingThe codes SHALL be taken from TreatmentTerminationReasonVS
TypeCodeableConcept
34. Procedure-argoprofile.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
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.

Max Length0
35. Procedure-argoprofile.identifier
Definition

This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Requirements

Need to allow connection to a wider workflow.

Max Length0
36. Procedure-argoprofile.subject
Definition

The person, animal or group on which the procedure was performed.

Control1..1
TypeReference(Patient)
Must Supporttrue
Max Length0
37. Procedure-argoprofile.status
Definition

A code specifying the state of the procedure. Generally this will be in-progress or completed state.

Control1..1
BindingThe codes SHALL be taken from ProcedureStatus
Typecode
Is Modifiertrue
Must Supporttrue
Max Length0
38. Procedure-argoprofile.category
Definition

A code that classifies the procedure for searching, sorting and display purposes (e.g. "Surgical Procedure").

Control0..1
BindingA code that classifies a procedure for searching, sorting and display purposes.
For example codes, see Procedure Category Codes (SNOMED CT)
TypeCodeableConcept
Max Length0
39. Procedure-argoprofile.code
Definition

The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. "Laparoscopic Appendectomy").

Control1..1
BindingThe codes SHALL be taken from RadiationProcedureVS; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Max Length0
40. Procedure-argoprofile.notPerformed
Definition

Set this to true if the record is saying that the procedure was NOT performed.

Control0..0
Typeboolean
Is Modifiertrue
Max Length0
Default Valuefalse
41. Procedure-argoprofile.reasonNotPerformed
Definition

A code indicating why the procedure was not performed.

Control0..0 This element is affected by the following invariants: pro-1
BindingA code that identifies the reason a procedure was not performed.
For example codes, see Procedure Not Performed Reason (SNOMED-CT)
TypeCodeableConcept
Max Length0
42. Procedure-argoprofile.bodySite
Definition

Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.

Control0..*
BindingThe codes SHALL be taken from RadiationTargetBodySiteVS; other codes may be used where these codes are not suitable
TypeCodeableConcept
Must Supporttrue
Max Length0
43. Procedure-argoprofile.bodySite.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
44. Procedure-argoprofile.bodySite.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

SlicingThis element introduces a set of slices on Procedure.bodySite.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
45. laterality
SliceNamelaterality
Definition

Body side of the body location, if needed to distinguish from a similar location on the other side of the body.

The laterality element is part of BodyLocation, a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases.

  • Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location.
  • Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation.
  • Relation to landmark: The location relative to a landmark is specified by:
  • Establishing the location and type of landmark using a body site code and optional laterality/orientation, and
  • Specifying the direction and distance from the landmark to the body location.

Note that BodyLocation is a data type (a reusable structure), not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR's stand-alone BodySite (aka BodyStructure in r4) which 'is not ... intended for describing the type of anatomical location but rather a specific body site on a specific patient' (FHIR 3.5).

Control0..*
TypeExtension(Laterality) (Extension Type: CodeableConcept)
46. anatomicalorientation
SliceNameanatomicalorientation
Definition

AnatomicalOrientation of the body location, if needed to distinguish from a similar location in another orientation. The orientation element is part of BodyLocation, a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases.

  • Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location.
  • Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation.
  • Relation to landmark: The location relative to a landmark is specified by:
  • Establishing the location and type of landmark using a body site code and optional laterality/orientation, and
  • Specifying the direction and distance from the landmark to the body location.

Note that BodyLocation is a data type (a reusable structure), not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR's stand-alone BodySite (aka BodyStructure in r4) which 'is not ... intended for describing the type of anatomical location but rather a specific body site on a specific patient' (FHIR 3.5).

Control0..*
TypeExtension(AnatomicalOrientation) (Extension Type: CodeableConcept)
47. relationtolandmark
SliceNamerelationtolandmark
Definition

The relationship between a landmark that helps determine a body location and the body location itself. The location relative to a landmark is specified by: * Specifying the location and type of landmark using a body site code and optional laterality/orientation, * Specifying the direction from the landmark to the body location, and * Specifying the distance from the landmark to the body location.

The RelationToLandmark element is part of BodyLocation, a flexible structure that allows the location to be determined by a single code, or a code plus laterality and/or orientation. The body location can also be specified in relation to one or more body landmarks. SNOMED CT is used in all cases.

  • Code only: The code should include (precoordinate) laterality and/orientation to the degree necessary to completely specify the body location.
  • Code plus laterality and/or orientation: The basic code augmented by codes specifying the body side and/or anatomical orientation.
  • Relation to landmark: The location relative to a landmark is specified by:
  • Establishing the location and type of landmark using a body site code and optional laterality/orientation, and
  • Specifying the direction and distance from the landmark to the body location.

Note that BodyLocation is a data type (a reusable structure), not a stand-alone entity. The concept is similar to how a postal address can apply to a person, location, or organization. This contrasts with FHIR's stand-alone BodySite (aka BodyStructure in r4) which 'is not ... intended for describing the type of anatomical location but rather a specific body site on a specific patient' (FHIR 3.5).

Control0..*
TypeExtension(RelationToLandmark) (Extension Type: Choice of: boolean, integer, decimal, base64Binary, instant, string, uri, date, dateTime, time, code, oid, id, unsignedInt, positiveInt, markdown, Annotation, Attachment, Identifier, CodeableConcept, Coding, Quantity, Range, Period, Ratio, SampledData, Signature, HumanName, Address, ContactPoint, Timing, Reference, Meta)
48. Procedure-argoprofile.bodySite.coding
Definition

A reference to a code defined by a terminology system.

Control0..*
TypeCoding
Requirements

Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.

49. Procedure-argoprofile.bodySite.text
Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Control0..1
Typestring
Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

50. Procedure-argoprofile.reasonx
Definition

Reference to a primary or secondary cancer condition.

Control0..1
BindingThe codes SHALL be taken from CancerDisorderVS; other codes may be used where these codes are not suitable
TypeChoice of: CodeableConcept, Reference(PrimaryCancerCondition | SecondaryCancerCondition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Comments

e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.

Max Length0
SlicingThis element introduces a set of slices on Procedure.reason[x]. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • type @ $this
51. Procedure-argoprofile.reasonReference-SecondaryCancerCondition
Definition

The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.

Control0..1
TypeReference(SecondaryCancerCondition)
52. Procedure-argoprofile.reasonReference-PrimaryCancerCondition
Definition

The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.

Control0..1
TypeReference(PrimaryCancerCondition)
53. Procedure-argoprofile.performer
Definition

Limited to 'real' people rather than equipment.

Control0..*
TypeBackboneElement
Max Length0
54. Procedure-argoprofile.performer.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
55. Procedure-argoprofile.performer.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

Max Length0
SlicingThis element introduces a set of slices on Procedure.performer.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • exists @ url
56. onbehalfof
SliceNameonbehalfof
Definition

The party represented by the actual participant.

Control0..*
TypeExtension(OnBehalfOf) (Extension Type: Reference(Practitioner | RelatedPerson | Patient | http://fhir.org/guides/argonaut/StructureDefinition/argo-device | Organization))
Max Length0
57. Procedure-argoprofile.performer.extension-onbehalfof.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
58. Procedure-argoprofile.performer.extension-onbehalfof.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..0
TypeExtension
Alternate Namesextensions, user content
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.

59. Procedure-argoprofile.performer.extension-onbehalfof.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Control1..1
Typeuri
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition should be version specific. This will ideally be the URI for the Resource Profile defining the extension, with the code for the extension after a #.

Fixed Valuehttp://mcodeinitiative.org/us/mcode/StructureDefinition/obf-OnBehalfOf-extension
60. Procedure-argoprofile.performer.extension-onbehalfof.val1
Definition

A formally or informally recognized grouping of people or organizations formed for the purpose of achieving some form of collective action. Includes companies, institutions, corporations, departments, community groups, healthcare practice groups, payer/insurer, etc.

Organization type is restricted to 0..1 in FHIR DSTU2, similarly restricted here. Other required attributes come from STU 3 mapping to us-core-organization.

Control1..1
TypeReference(Organization)
61. Procedure-argoprofile.performer.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
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.

Max Length0
62. Procedure-argoprofile.performer.actor
Definition

Constrains participants to classes that are accepted by FHIR as actors in procedures in STU 3.

Control0..1
TypeReference(Practitioner)
Max Length0
63. Procedure-argoprofile.performer.role
Definition

For example: surgeon, anaethetist, endoscopist.

Control0..1
BindingA code that identifies the role of a performer of the procedure.
For example codes, see Procedure Performer Role Codes
TypeCodeableConcept
Max Length0
64. Procedure-argoprofile.performedx
Definition

The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.

Control1..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Max Length0
65. Procedure-argoprofile.encounter
Definition

The encounter during which the procedure was performed.

Control0..1
TypeReference(Encounter)
Max Length0
66. Procedure-argoprofile.location
Definition

The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant.

Control0..1
TypeReference(Location)
Requirements

Ties a procedure to where the records are likely kept.

Max Length0
67. Procedure-argoprofile.outcome
Definition

The outcome of the procedure - did it resolve reasons for the procedure being performed?

Control0..1
BindingAn outcome of a procedure - whether it was resolved or otherwise.
For example codes, see Procedure Outcome Codes (SNOMED CT)
TypeCodeableConcept
Comments

If outcome contains narrative text only, it can be captured using the CodeableConcept.text.

Max Length0
68. Procedure-argoprofile.report
Definition

This could be a histology result, pathology report, surgical report, etc..

Control0..*
TypeReference(DiagnosticReport)
Comments

There could potentially be multiple reports - e.g. if this was a procedure which took multiple biopsies resulting in a number of anatomical pathology reports.

Max Length0
69. Procedure-argoprofile.complication
Definition

Any complications that occurred during the procedure, or in the immediate post-performance period. These are generally tracked separately from the notes, which will typically describe the procedure itself rather than any 'post procedure' issues.

Control0..*
BindingCodes describing complications that resulted from a procedure.
For example codes, see Condition/Problem/Diagnosis Codes
TypeCodeableConcept
Comments

If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text.

Max Length0
70. Procedure-argoprofile.followUp
Definition

If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.

Control0..*
BindingSpecific follow up required for a procedure e.g. removal of sutures.
For example codes, see Procedure Follow up Codes (SNOMED CT)
TypeCodeableConcept
Max Length0
71. Procedure-argoprofile.request
Definition

A request for this procedure.

Control0..1
TypeReference(ProcedureRequest | ReferralRequest)
Max Length0
72. Procedure-argoprofile.notes
Definition

Any other notes about the procedure. E.g. the operative notes.

Control0..*
TypeAnnotation(Annotation)
Max Length0
73. Procedure-argoprofile.focalDevice
Definition

A device that is implanted, removed or otherwise manipulated (calibration, battery replacement, fitting a prosthesis, attaching a wound-vac, etc.) as a focal portion of the Procedure.

Control0..0
TypeBackboneElement
Max Length0
74. Procedure-argoprofile.focalDevice.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Max Length0
75. Procedure-argoprofile.focalDevice.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

Max Length0
76. Procedure-argoprofile.focalDevice.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order 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 is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
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.

Max Length0
77. Procedure-argoprofile.focalDevice.action
Definition

The kind of change that happened to the device during the procedure.

Control0..1
BindingA kind of change that happened to the device during the procedure.
The codes SHALL be taken from Procedure Device Action Codes
TypeCodeableConcept
Max Length0
78. Procedure-argoprofile.focalDevice.manipulated
Definition

The device that was manipulated (changed) during the procedure.

Control1..1
TypeReference(http://fhir.org/guides/argonaut/StructureDefinition/argo-device)
Max Length0
79. Procedure-argoprofile.used
Definition

Identifies medications, devices and any other substance used as part of the procedure.

Control0..*
TypeReference(http://fhir.org/guides/argonaut/StructureDefinition/argo-device | http://fhir.org/guides/argonaut/StructureDefinition/argo-medication | Substance)
Requirements

Used for tracking contamination, etc.

Comments

For devices actually implanted or removed, use Procedure.device.

Max Length0