HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE), v0.9.0

- Local Development build (v0.9.0). See the Directory of published versions

SurgicalProcedure

 

The official URL for this profile is:

http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-SurgicalProcedure

This profile builds on http://fhir.org/guides/argonaut/StructureDefinition/argo-procedure.

This profile was published on Wed Apr 17 00:00:00 EDT 2019 as a draft by The MITRE Corporation.

Summary

Prohibited: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

shr.core.SurgicalProcedure maps to http://fhir.org/guides/argonaut/StructureDefinition/argo-procedure:
  _Entry.EntryId maps to id
  Language maps to language
  Narrative maps to text
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Identifier maps to identifier
  Code maps to code
  PatientSubjectOfRecord maps to subject
  Category maps to category
  constrain notPerformed to 0..0
  constrain reasonNotPerformed to 0..0
  SurgicalBodyLocation.LocationCode maps to bodySite
  SurgicalBodyLocation.Laterality maps to bodySite.extension
  SurgicalBodyLocation.Orientation maps to bodySite.extension
  SurgicalBodyLocation.RelationToLandmark maps to bodySite.extension
  Annotation maps to notes
  CareContext maps to encounter
  OccurrenceTimeOrPeriod maps to performed[x]
  Participation maps to performer
  Participation.Participant maps to performer.actor
  Participation.ParticipationType maps to performer.role
  Status maps to status
  RelatedRequest.MedicationRequest maps to request
  RelatedRequest.ProcedureRequest maps to request
  RelatedRequest.ReferralRequest maps to request
  Outcome maps to outcome
  Location maps to location
  MaterialUsed maps to used
  FocalDevice maps to focalDevice
  SurgicalBodyLocation.SurgicalBodyLocationRole maps to bodySite.extension

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure shr-core-SurgicalProcedure
... extension Slice: Unordered, Open by value:url
... shr-core-StatementDateTime-extension 0..1dateTimeStatementDateTime
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-StatementDateTime-extension
... shr-core-ReasonCode-extension 0..*CodeableConceptReasonCode
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonCode-extension
... shr-core-ReasonReference-extension 0..*Reference(shr-core-Condition | shr-core-Observation)ReasonReference
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonReference-extension
... shr-core-PartOf-extension 0..1Reference(shr-core-DomainResource)PartOf
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-PartOf-extension
.... valueReference Reference(shr-core-Procedure)Procedure
... shr-core-TreatmentIntent-extension 0..1CodeableConceptTreatmentIntent
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-TreatmentIntent-extension
Binding: TreatmentIntentVS (required)
... subject Reference(shr-core-Patient)
... code Binding: SurgicalProcedureVS (extensible)
... notPerformed 0..0
... reasonNotPerformed 0..0
... bodySite Binding: BodyLocationVS (preferred)
.... extension Slice: Unordered, Open by value:url
.... shr-core-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Laterality-extension
Binding: LateralityVS (extensible)
.... shr-core-Orientation-extension 0..*CodeableConceptOrientation
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Orientation-extension
Binding: OrientationVS (extensible)
.... shr-core-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-RelationToLandmark-extension
.... shr-core-SurgicalBodyLocationRole-extension 0..*(Complex)SurgicalBodyLocationRole
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-SurgicalBodyLocationRole-extension
... performer
.... actor Reference(shr-core-Practitioner)
... encounter Reference(shr-core-Encounter)
... location Reference(shr-core-Location)
... request Reference(shr-core-ProcedureRequest)
... notes Annotation
... used Reference(shr-core-Device | shr-core-Medication | shr-core-Substance)

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*shr-core-SurgicalProcedure
pro-1: Reason not performed is only permitted if notPerformed indicator is true
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: http://tools.ietf.org/html/bcp47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
... shr-core-StatementDateTime-extension 0..1dateTimeStatementDateTime
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-StatementDateTime-extension
... shr-core-ReasonCode-extension 0..*CodeableConceptReasonCode
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonCode-extension
... shr-core-ReasonReference-extension 0..*Reference(shr-core-Condition | shr-core-Observation)ReasonReference
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonReference-extension
... shr-core-PartOf-extension 0..1Reference(shr-core-DomainResource)PartOf
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-PartOf-extension
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-PartOf-extension"
.... valueReference 1..1Reference(shr-core-Procedure)Procedure
... shr-core-TreatmentIntent-extension 0..1CodeableConceptTreatmentIntent
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-TreatmentIntent-extension
Binding: TreatmentIntentVS (required)
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... subject S1..1Reference(shr-core-Patient)Who the procedure was performed on
... status ?!S1..1codein-progress | aborted | completed | entered-in-error
Binding: ProcedureStatus (required)
... category Σ0..1CodeableConceptClassification of the procedure
Binding: Procedure Category Codes (SNOMED CT) (example)
... code S1..1CodeableConceptSNOMED-CT | ICD-10 | CPT-4
Binding: SurgicalProcedureVS (extensible)
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: BodyLocationVS (preferred)
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... shr-core-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Laterality-extension
Binding: LateralityVS (extensible)
.... shr-core-Orientation-extension 0..*CodeableConceptOrientation
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Orientation-extension
Binding: OrientationVS (extensible)
.... shr-core-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-RelationToLandmark-extension
.... shr-core-SurgicalBodyLocationRole-extension 0..*(Complex)SurgicalBodyLocationRole
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-SurgicalBodyLocationRole-extension
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... reason[x] Σ0..1CodeableConcept, Reference(Condition)Reason procedure performed
Binding: Procedure Reason Codes (example)
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... actor Σ0..1Reference(shr-core-Practitioner)The reference to the practitioner
.... role Σ0..1CodeableConceptThe role the actor was in
Binding: Procedure Performer Role Codes (example)
... performed[x] S1..1dateTime, PeriodDate/Period the procedure was performed
... encounter Σ0..1Reference(shr-core-Encounter)The encounter associated with the procedure
... location Σ0..1Reference(shr-core-Location)Where the procedure happened
... outcome Σ0..1CodeableConceptThe result of procedure
Binding: Procedure Outcome Codes (SNOMED CT) (example)
... report 0..*Reference(DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/Diagnosis Codes (example)
... followUp 0..*CodeableConceptInstructions for follow up
Binding: Procedure Follow up Codes (SNOMED CT) (example)
... request 0..1Reference(shr-core-ProcedureRequest)A request for this procedure
... notes 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementDevice changed in procedure
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... action 0..1CodeableConceptKind of change to device
Binding: Procedure Device Action Codes (required)
.... manipulated 1..1Reference(Device)Device that was changed
... used 0..*Reference(shr-core-Device | shr-core-Medication | shr-core-Substance)Items used during procedure

doco Documentation for this format

Summary

Prohibited: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Mapping Source

This structure represents the following mapping definition:

shr.core.SurgicalProcedure maps to http://fhir.org/guides/argonaut/StructureDefinition/argo-procedure:
  _Entry.EntryId maps to id
  Language maps to language
  Narrative maps to text
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Identifier maps to identifier
  Code maps to code
  PatientSubjectOfRecord maps to subject
  Category maps to category
  constrain notPerformed to 0..0
  constrain reasonNotPerformed to 0..0
  SurgicalBodyLocation.LocationCode maps to bodySite
  SurgicalBodyLocation.Laterality maps to bodySite.extension
  SurgicalBodyLocation.Orientation maps to bodySite.extension
  SurgicalBodyLocation.RelationToLandmark maps to bodySite.extension
  Annotation maps to notes
  CareContext maps to encounter
  OccurrenceTimeOrPeriod maps to performed[x]
  Participation maps to performer
  Participation.Participant maps to performer.actor
  Participation.ParticipationType maps to performer.role
  Status maps to status
  RelatedRequest.MedicationRequest maps to request
  RelatedRequest.ProcedureRequest maps to request
  RelatedRequest.ReferralRequest maps to request
  Outcome maps to outcome
  Location maps to location
  MaterialUsed maps to used
  FocalDevice maps to focalDevice
  SurgicalBodyLocation.SurgicalBodyLocationRole maps to bodySite.extension

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure shr-core-SurgicalProcedure
... extension Slice: Unordered, Open by value:url
... shr-core-StatementDateTime-extension 0..1dateTimeStatementDateTime
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-StatementDateTime-extension
... shr-core-ReasonCode-extension 0..*CodeableConceptReasonCode
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonCode-extension
... shr-core-ReasonReference-extension 0..*Reference(shr-core-Condition | shr-core-Observation)ReasonReference
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonReference-extension
... shr-core-PartOf-extension 0..1Reference(shr-core-DomainResource)PartOf
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-PartOf-extension
.... valueReference Reference(shr-core-Procedure)Procedure
... shr-core-TreatmentIntent-extension 0..1CodeableConceptTreatmentIntent
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-TreatmentIntent-extension
Binding: TreatmentIntentVS (required)
... subject Reference(shr-core-Patient)
... code Binding: SurgicalProcedureVS (extensible)
... notPerformed 0..0
... reasonNotPerformed 0..0
... bodySite Binding: BodyLocationVS (preferred)
.... extension Slice: Unordered, Open by value:url
.... shr-core-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Laterality-extension
Binding: LateralityVS (extensible)
.... shr-core-Orientation-extension 0..*CodeableConceptOrientation
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Orientation-extension
Binding: OrientationVS (extensible)
.... shr-core-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-RelationToLandmark-extension
.... shr-core-SurgicalBodyLocationRole-extension 0..*(Complex)SurgicalBodyLocationRole
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-SurgicalBodyLocationRole-extension
... performer
.... actor Reference(shr-core-Practitioner)
... encounter Reference(shr-core-Encounter)
... location Reference(shr-core-Location)
... request Reference(shr-core-ProcedureRequest)
... notes Annotation
... used Reference(shr-core-Device | shr-core-Medication | shr-core-Substance)

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure I0..*shr-core-SurgicalProcedure
pro-1: Reason not performed is only permitted if notPerformed indicator is true
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: http://tools.ietf.org/html/bcp47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
... shr-core-StatementDateTime-extension 0..1dateTimeStatementDateTime
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-StatementDateTime-extension
... shr-core-ReasonCode-extension 0..*CodeableConceptReasonCode
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonCode-extension
... shr-core-ReasonReference-extension 0..*Reference(shr-core-Condition | shr-core-Observation)ReasonReference
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-ReasonReference-extension
... shr-core-PartOf-extension 0..1Reference(shr-core-DomainResource)PartOf
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-PartOf-extension
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-PartOf-extension"
.... valueReference 1..1Reference(shr-core-Procedure)Procedure
... shr-core-TreatmentIntent-extension 0..1CodeableConceptTreatmentIntent
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-TreatmentIntent-extension
Binding: TreatmentIntentVS (required)
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... subject S1..1Reference(shr-core-Patient)Who the procedure was performed on
... status ?!S1..1codein-progress | aborted | completed | entered-in-error
Binding: ProcedureStatus (required)
... category Σ0..1CodeableConceptClassification of the procedure
Binding: Procedure Category Codes (SNOMED CT) (example)
... code S1..1CodeableConceptSNOMED-CT | ICD-10 | CPT-4
Binding: SurgicalProcedureVS (extensible)
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: BodyLocationVS (preferred)
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
Slice: Unordered, Open by value:url
.... shr-core-Laterality-extension 0..*CodeableConceptLaterality
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Laterality-extension
Binding: LateralityVS (extensible)
.... shr-core-Orientation-extension 0..*CodeableConceptOrientation
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-Orientation-extension
Binding: OrientationVS (extensible)
.... shr-core-RelationToLandmark-extension 0..*(Complex)RelationToLandmark
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-RelationToLandmark-extension
.... shr-core-SurgicalBodyLocationRole-extension 0..*(Complex)SurgicalBodyLocationRole
URL: http://hl7.org/fhir/us/shr/StructureDefinition/shr-core-SurgicalBodyLocationRole-extension
.... coding Σ0..*CodingCode defined by a terminology system
.... text Σ0..1stringPlain text representation of the concept
... reason[x] Σ0..1CodeableConcept, Reference(Condition)Reason procedure performed
Binding: Procedure Reason Codes (example)
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... actor Σ0..1Reference(shr-core-Practitioner)The reference to the practitioner
.... role Σ0..1CodeableConceptThe role the actor was in
Binding: Procedure Performer Role Codes (example)
... performed[x] S1..1dateTime, PeriodDate/Period the procedure was performed
... encounter Σ0..1Reference(shr-core-Encounter)The encounter associated with the procedure
... location Σ0..1Reference(shr-core-Location)Where the procedure happened
... outcome Σ0..1CodeableConceptThe result of procedure
Binding: Procedure Outcome Codes (SNOMED CT) (example)
... report 0..*Reference(DiagnosticReport)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/Diagnosis Codes (example)
... followUp 0..*CodeableConceptInstructions for follow up
Binding: Procedure Follow up Codes (SNOMED CT) (example)
... request 0..1Reference(shr-core-ProcedureRequest)A request for this procedure
... notes 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementDevice changed in procedure
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
.... action 0..1CodeableConceptKind of change to device
Binding: Procedure Device Action Codes (required)
.... manipulated 1..1Reference(Device)Device that was changed
... used 0..*Reference(shr-core-Device | shr-core-Medication | shr-core-Substance)Items used during procedure

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
Procedure.statusrequiredProcedureStatus
Procedure.codeextensibleSurgicalProcedureVS

 

Constraints

IdPathDetailsRequirements
pro-1ProcedureReason not performed is only permitted if notPerformed indicator is true
: