MII IG Befunde bildgebender Verfahren DE v2025

ReadProcedure

Diese Procedure-Ressource wird verwendet, um eine Befundungsprozedur zu erfassen. Hier wird festgelegt, dass es sich rein um eine radiologische Befundungsprozedur handelt.

Name	Status	Version	Canonical	Basis
MII_PR_Bildgebung_Radiologische_Befundungsprozedur	active	2025.0.0	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-befundungsprozedur	https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Procedure

Inhalt

MII_PR_Bildgebung_Radiologische_Befundungsprozedur (Procedure)	I		MII_PR_Prozedur_Procedure	There are no (further) constraints on this element Element id Procedure Short description An action that is being or was performed on a patient Definition An action that is or was performed on or for a patient. This can be a physical intervention like an operation, or less invasive like long term services, counseling, or hypnotherapy. Data type MII_PR_Prozedur_Procedure Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: 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-3: 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-6: A resource should have narrative for robust management text.`div`.exists() dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` proc-mii-1: Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden `code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()` Mappings rim: Entity. Role, or Act workflow: Event rim: Procedure[moodCode=EVN]
id	S Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. 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. Data type string
meta	S Σ	0..1	Meta	There are no (further) constraints on this element Element id Procedure.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
id		0..1	string	There are no (further) constraints on this element Element id Procedure.meta.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.meta.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id Procedure.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. 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. Data type id Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
lastUpdated	Σ	0..1	instant	There are no (further) constraints on this element Element id Procedure.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed. 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. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
source	S Σ	0..1	uri	There are no (further) constraints on this element Element id Procedure.meta.source Short description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. 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. Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
profile	S Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id Procedure.meta.profile Short description Profiles this resource claims to conform to Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. 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. Data type canonical(StructureDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id Procedure.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. 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. Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id Procedure.meta.tag Short description Tags applied to this resource 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. 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. Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Procedure.implicitRules Short description A set of rules under which this content was created 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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
language		0..1	codeBinding	There are no (further) constraints on this element Element id Procedure.language Short description Language of the resource content Definition The base language in which the resource is written. 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). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
text		0..1	Narrative	There are no (further) constraints on this element Element id Procedure.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can 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. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id Procedure.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources 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. 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: Entity. Role, or Act rim: N/A
extension	S I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Dokumentationsdatum	S I	0..1	Extension(dateTime)	There are no (further) constraints on this element Element id Procedure.extension:Dokumentationsdatum Short description Dokumentationsdatum Alternate names extensions, user content Definition Dokumentationsdatum der Prozedur, falls abweichend vom Durchführungsdatum 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. Data type Extension(dateTime) Extension URL http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
durchfuehrungsabsicht	S I	0..1	Extension(Coding)	There are no (further) constraints on this element Element id Procedure.extension:durchfuehrungsabsicht Short description Durchführungsabsicht Alternate names extensions, user content Definition therapeutisch \| palliativ \| diagnostisch \| präventiv \| rehabilitativ \| andere 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. Data type Extension(Coding) Extension URL https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content 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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id Procedure.identifier Short description External Identifiers for this procedure Definition Business identifiers assigned to this procedure by the performer or other systems which remain constant as the resource is updated and is propagated from server to server. Requirements Allows identification of the procedure as it is known by various participating systems and in a way that remains consistent across servers. Comments This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and Person resource instances might share the same social insurance number. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier v2: Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4 rim: .id
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire)	There are no (further) constraints on this element Element id Procedure.instantiatesCanonical Short description Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. Comments see Canonical References Data type canonical(PlanDefinition \| ActivityDefinition \| Measure \| OperationDefinition \| Questionnaire) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.instantiatesCanonical rim: .outboundRelationship[typeCode=DEFN].target
instantiatesUri	Σ	0..*	uri	There are no (further) constraints on this element Element id Procedure.instantiatesUri Short description Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, order set or other definition that is adhered to in whole or in part by this Procedure. Comments This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.instantiatesUri rim: .outboundRelationship[typeCode=DEFN].target
basedOn	Σ I	0..*	Reference(CarePlan \| ServiceRequest)	There are no (further) constraints on this element Element id Procedure.basedOn Short description A request for this procedure Alternate names fulfills Definition A reference to a resource that contains details of the request for this procedure. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(CarePlan \| ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.basedOn rim: .outboundRelationship[typeCode=FLFS].target[classCode=(various e.g. PROC, OBS, PCPR, ACT, moodCode=RQO].code
partOf	Σ I	0..*	Reference(Procedure \| Observation \| MedicationAdministration)	There are no (further) constraints on this element Element id Procedure.partOf Short description Part of referenced event Alternate names container Definition A larger event of which this particular procedure is a component or step. Comments The MedicationAdministration resource has a partOf reference to Procedure, but this is not a circular reference. For example, the anesthesia MedicationAdministration is part of the surgical Procedure (MedicationAdministration.partOf = Procedure). For example, the procedure to insert the IV port for an IV medication administration is part of the medication administration (Procedure.partOf = MedicationAdministration). Data type Reference(Procedure \| Observation \| MedicationAdministration) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.partOf rim: .inboundRelationship[typeCode=COMP].source[classCode=SBADM or PROC or OBS, moodCode=EVN]
status	S Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id Procedure.status Short description Status Definition Vorbereitung \| in Arbeit \| nicht durchgeführt \| pausiert \| abgebrochen \| abgeschlossen \| Eingabe fehlerhaft \| unbekannt Comments The "unknown" code is not to be used to convey other statuses. The "unknown" code should be used when one of the statuses applies, but the authoring system doesn't know the current state of the procedure. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding A code specifying the state of the procedure. EventStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.status w5: FiveWs.status rim: statusCode
statusReason	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.statusReason Short description Reason for current status Alternate names Suspended Reason, Cancelled Reason Definition Captures the reason for the current state of the procedure. Comments This is generally only used for "exception" statuses such as "not-done", "suspended" or "aborted". The reason for performing the event at all is captured in reasonCode, not here. Data type CodeableConcept Binding A code that identifies the reason a procedure was not performed. ProcedureNotPerformedReason(SNOMED-CT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.statusReason rim: .reason.Observation.value
category	S Σ	1..1	CodeableConceptPattern	Element id Procedure.category Short description Kategorie Definition Diagnostische Maßnahmen \| Bildgebende Diagnostik \| Operationen \| Medikamente \| Nichtoperative therapeutische Maßnahmen \| Ergänzende Maßnahmen Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding A code that classifies a procedure for searching, sorting and display purposes. ProcedureCategoryCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "coding": [ { "system": "http://snomed.info/sct", "code": "165197003" } ] } Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD w5: FiveWs.class rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
id		0..1	string	There are no (further) constraints on this element Element id Procedure.category.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.category.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
coding	Σ	0..*	CodingPattern	There are no (further) constraints on this element Element id Procedure.category.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. 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 labeled as UserSelected = true. Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://snomed.info/sct", "code": "165197003" } Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
sct	S Σ	0..1	CodingBindingPattern	There are no (further) constraints on this element Element id Procedure.category.coding:sct Short description SNOMED CT Code Definition Ein Verweis auf einen von SNOMED CT definierten Code Requirements Allows for alternative encodings within a code system, and translations to other code systems. 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 labeled as UserSelected = true. Data type Coding Binding MII_VS_Prozedur_OpsKategorien_SNOMEDCT (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://snomed.info/sct" } Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id Procedure.category.coding:sct.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.category.coding:sct.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
system	S Σ	1..1	uriPattern	There are no (further) constraints on this element Element id Procedure.category.coding:sct.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://snomed.info/sct Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.category.coding:sct.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	There are no (further) constraints on this element Element id Procedure.category.coding:sct.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.category.coding:sct.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id Procedure.category.coding:sct.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.category.text Short description Plain text representation of the concept 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. 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
code	S Σ I	1..1	CodeableConcept	Element id Procedure.code Short description Code Alternate names type Definition ode aus OPS - Operationen- und Prozedurenschlüssel, SNOMED CT oder andere. Requirements 0..1 to account for primarily narrative only resources. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding A code to identify a specific procedure . ProcedureCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` sct-ops-1: Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden. `coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.what[x] v2: OBR-44/OBR-45 rim: .code
id		0..1	string	There are no (further) constraints on this element Element id Procedure.code.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.code.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
coding	S Σ	1..*	Coding	There are no (further) constraints on this element Element id Procedure.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. 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 labeled as UserSelected = true. Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
ops	S Σ	0..1	CodingOPSBindingPattern	There are no (further) constraints on this element Element id Procedure.code.coding:ops Short description Operationen- und Prozedurenschlüssel (OPS) Code Definition Ein Verweis auf einen vom Operationen- und Prozedurenschlüssel (OPS) definierten Code Requirements Allows for alternative encodings within a code system, and translations to other code systems. 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. Data type CodingOPS Binding OpsVS (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://fhir.de/CodeSystem/bfarm/ops" } Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:ops.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.code.coding:ops.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Seitenlokalisation	S I	0..1	Extension(Coding)	There are no (further) constraints on this element Element id Procedure.code.coding:ops.extension:Seitenlokalisation Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. 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. Data type Extension(Coding) Extension URL http://fhir.de/StructureDefinition/seitenlokalisation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
system	S Σ	1..1	uriFixed ValuePattern	There are no (further) constraints on this element Element id Procedure.code.coding:ops.system Short description Canonische CodeSystem URL für OPS Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Fixed value http://fhir.de/CodeSystem/bfarm/ops Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	S Σ	1..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:ops.version Short description Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie Verwendung von OPS ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von OPS ein neues Codesystem darstellt. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ I	1..1	code	There are no (further) constraints on this element Element id Procedure.code.coding:ops.code Short description Der OPS-Code Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ops-regex: In code sind nur gültige OPS-Codes ohne Zusätze erlaubt `matches('^[1\|3\|5\|6\|8\|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')` Examples Einfacher OPS-Code 5-470 Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:ops.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id Procedure.code.coding:ops.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
sct	S Σ	0..1	CodingBindingPattern	There are no (further) constraints on this element Element id Procedure.code.coding:sct Short description SNOMED CT Code Definition Ein Verweis auf einen von SNOMED CT definierten Code Requirements Allows for alternative encodings within a code system, and translations to other code systems. 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 labeled as UserSelected = true. Data type Coding Binding MII_VS_Prozedur_Prozeduren_SNOMEDCT (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://snomed.info/sct" } Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:sct.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.code.coding:sct.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
system	S Σ	1..1	uriPattern	There are no (further) constraints on this element Element id Procedure.code.coding:sct.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://snomed.info/sct Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:sct.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	There are no (further) constraints on this element Element id Procedure.code.coding:sct.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.code.coding:sct.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id Procedure.code.coding:sct.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element id Procedure.code.text Short description Plain text representation of the concept 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. 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
subject	S Σ I	1..1	Reference(Patient)	Element id Procedure.subject Short description Person Alternate names patient Definition Person, auf die sich die Befundungprozedur bezieht Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 rim: .participation[typeCode=SBJ].role w5: FiveWs.subject
encounter	Σ I	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id Procedure.encounter Short description Encounter created as part of Definition The Encounter during which this Procedure was created or performed or to which the creation of this record is tightly associated. Comments This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.context w5: FiveWs.context v2: PV1-19 rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
performed[x]	S Σ	1..1		There are no (further) constraints on this element Element id Procedure.performed[x] Short description Durchführungsdatum Definition Durchführungsdatum oder -zeitraum der Prozedur. Comments Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. Sliced: Unordered, Open, by $this(Type) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: .effectiveTime
performedDateTime	Σ	0..1	dateTime	There are no (further) constraints on this element Element id Procedure.performed[x]:performedDateTime Short description When the procedure was performed Definition Durchführungsdatum der Prozedur. Comments Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: .effectiveTime
performedPeriod	Σ	0..1	Period	There are no (further) constraints on this element Element id Procedure.performed[x]:performedPeriod Short description Durchführungszeitraum Definition Zeitraum, in dem die Prozedur durchgeführt wurde. Comments Age is generally used when the patient reports an age at which the procedure was performed. Range is generally used when the patient reports an age range when the procedure was performed, such as sometime between 20-25 years old. dateTime supports a range of precision due to some procedures being reported as past procedures that might not have millisecond precision while other procedures performed and documented during the encounter might have more precise UTC timestamps with timezone. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: .effectiveTime
recorder	Σ I	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	There are no (further) constraints on this element Element id Procedure.recorder Short description Who recorded the procedure Definition Individual who recorded the record and takes responsibility for its content. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5: FiveWs.author rim: .participation[typeCode=AUT].role
asserter	Σ I	0..1	Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole)	There are no (further) constraints on this element Element id Procedure.asserter Short description Person who asserts this procedure Definition Individual who is making the procedure statement. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Patient \| RelatedPerson \| Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5: FiveWs.source rim: .participation[typeCode=INF].role
performer	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element id Procedure.performer Short description The people who performed the procedure Definition Limited to "real" people rather than equipment. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.performer rim: .participation[typeCode=PRF]
id		0..1	string	There are no (further) constraints on this element Element id Procedure.performer.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.performer.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.performer.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
function	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.performer.function Short description Type of performance Definition Distinguishes the type of involvement of the performer in the procedure. For example, surgeon, anaesthetist, endoscopist. Requirements Allows disambiguation of the types of involvement of different performers. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding A code that identifies the role of a performer of the procedure. ProcedurePerformerRoleCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.performer.function v2: Some combination of STF-18 / PRA-3 / PRT-4 / ROL-3 / ORC-12 / OBR-16 / PV1-7 / PV1-8 / PV1-9 / PV1-17 / OBX-25 rim: .functionCode
actor	Σ I	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	There are no (further) constraints on this element Element id Procedure.performer.actor Short description The reference to the practitioner Definition The practitioner who was involved in the procedure. Requirements A reference to Device supports use cases, such as pacemakers. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.performer.actor w5: FiveWs.actor v2: ORC-19/PRT-5 rim: .role
onBehalfOf	I	0..1	Reference(Organization)	There are no (further) constraints on this element Element id Procedure.performer.onBehalfOf Short description Organization the device or practitioner was acting for Definition The organization the device or practitioner was acting on behalf of. Requirements Practitioners and Devices can be associated with multiple organizations. This element indicates which organization they were acting on behalf of when performing the action. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .scoper
location	Σ I	0..1	Reference(Location)	There are no (further) constraints on this element Element id Procedure.location Short description Where the procedure happened Definition The location where the procedure actually happened. E.g. a newborn at home, a tracheostomy at a restaurant. Requirements Ties a procedure to where the records are likely kept. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Location) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5: FiveWs.where[x] rim: .participation[typeCode=LOC].role[classCode=SDLOC]
reasonCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.reasonCode Short description Coded reason procedure performed Definition The coded reason why the procedure was performed. This may be a coded entity of some type, or may simply be present as text. Comments Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Data type CodeableConcept Binding A code that identifies the reason a procedure is required. ProcedureReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.reasonCode w5: FiveWs.why[x] rim: .reasonCode
reasonReference	Σ I	0..*	Reference(Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference)	There are no (further) constraints on this element Element id Procedure.reasonReference Short description The justification that the procedure was performed Definition The justification of why the procedure was performed. Comments It is possible for a procedure to be a reason (such as C-Section) for another procedure (such as an epidural). Other examples include endoscopy for dilatation and biopsy (a combination of diagnostic and therapeutic use). Use Procedure.reasonCode when a code sufficiently describes the reason. Use Procedure.reasonReference when referencing a resource, which allows more information to be conveyed, such as onset date. Procedure.reasonCode and Procedure.reasonReference are not meant to be duplicative. For a single reason, either Procedure.reasonCode or Procedure.reasonReference can be used. Procedure.reasonCode may be a summary code, or Procedure.reasonReference may be used to reference a very precise definition of the reason using Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference. Both Procedure.reasonCode and Procedure.reasonReference can be used if they are describing different reasons for the procedure. Data type Reference(Condition \| Observation \| Procedure \| DiagnosticReport \| DocumentReference) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.reasonReference w5: FiveWs.why[x] rim: .reasonCode
bodySite	S Σ	0..*	CodeableConceptBinding	There are no (further) constraints on this element Element id Procedure.bodySite Short description Körperstelle Definition Körperstelle der Prozedur mittels SNOMED CT inklusive Lateralität. Comments If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension procedure-targetbodystructure. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: OBX-20 rim: .targetSiteCode
outcome	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Procedure.outcome Short description The result of procedure Definition The outcome of the procedure - did it resolve the reasons for the procedure being performed? Comments If outcome contains narrative text only, it can be captured using the CodeableConcept.text. Data type CodeableConcept Binding An outcome of a procedure - whether it was resolved or otherwise. ProcedureOutcomeCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .outboundRelationship[typeCode=OUT].target.text
report	S I	1..*	Reference(DiagnosticReport \| DocumentReference \| Composition)	Element id Procedure.report Short description Bericht Definition Referenz auf den Bericht 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. Data type Reference(DiagnosticReport \| DocumentReference \| Composition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]
complication		0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.complication Short description Complication following the procedure 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. Comments If complications are only expressed by the narrative text, they can be captured using the CodeableConcept.text. Data type CodeableConcept Binding Codes describing complications that resulted from a procedure. Condition/Problem/DiagnosisCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
complicationDetail	I	0..*	Reference(Condition)	There are no (further) constraints on this element Element id Procedure.complicationDetail Short description A condition that is a result of the procedure Definition Any complications that occurred during the procedure, or in the immediate post-performance period. Requirements This is used to document a condition that is a result of the procedure, not the condition that was the reason for the procedure. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Condition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .outboundRelationship[typeCode=OUTC].target[classCode=OBS, code="complication", moodCode=EVN].value
followUp		0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.followUp Short description Instructions for follow up Definition If the procedure required specific follow up - e.g. removal of sutures. The follow up may be represented as a simple note or could potentially be more complex, in which case the CarePlan resource can be used. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding Specific follow up required for a procedure e.g. removal of sutures. ProcedureFollowUpCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code
note	S	0..*	Annotation	There are no (further) constraints on this element Element id Procedure.note Short description Hinweis Definition Zusätzliche Informationen zur Prozedur als Freitext. Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: N/A rim: Act workflow: Event.note v2: NTE rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
focalDevice		0..*	BackboneElement	There are no (further) constraints on this element Element id Procedure.focalDevice Short description Manipulated, implanted, or removed device 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. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: .participation[typeCode=DEV].role[classCode=MANU]
id		0..1	string	There are no (further) constraints on this element Element id Procedure.focalDevice.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.focalDevice.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Procedure.focalDevice.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
action		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Procedure.focalDevice.action Short description Kind of change to device Definition The kind of change that happened to the device during the procedure. Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Binding A kind of change that happened to the device during the procedure. ProcedureDeviceActionCodes (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="procedure device action"].value=:procedure device action codes
manipulated	I	1..1	Reference(Device)	There are no (further) constraints on this element Element id Procedure.focalDevice.manipulated Short description Device that was changed Definition The device that was manipulated (changed) during the procedure. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Device) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .participation[typeCode=DEV].role[classCode=SDLOC]
usedReference	I	0..*	Reference(Device \| Medication \| Substance)	There are no (further) constraints on this element Element id Procedure.usedReference Short description Items used during procedure Definition Identifies medications, devices and any other substance used as part of the procedure. Requirements Used for tracking contamination, etc. Comments For devices actually implanted or removed, use Procedure.device. Data type Reference(Device \| Medication \| Substance) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim: .participation[typeCode=DEV].role[classCode=MANU] or .participation[typeCode=CSM].role[classCode=ADMM] (for Medication or Substance)
usedCode		0..*	CodeableConcept	There are no (further) constraints on this element Element id Procedure.usedCode Short description Coded items used during the procedure Definition Identifies coded items that were used as part of the procedure. Comments For devices actually implanted or removed, use Procedure.device. Data type CodeableConcept Binding Codes describing items used during a procedure. FHIRDeviceTypes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD rim: participation[typeCode=Dev].role[classCode=MANU]

Diese Profil beschreibt die radiologische Befundungsprozedur. Es legt fest, dass es sich hierbei um eine reine diagnostische Prozedur handelt

Feldname	Kurzbeschreibung
Procedure.report	Bericht

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-bildgebung-radiologische-befundungsprozedur" />
    <extension url="https://www.medizininformatik-initiative.de/fhir/modul-meta/StructureDefinition/mii-ex-meta-license-codeable">
        <valueCodeableConcept>
            <coding>
                <system value="http://hl7.org/fhir/spdx-license" />
                <code value="CC-BY-4.0" />
                <display value="Creative Commons Attribution 4.0 International" />
            </coding>
        </valueCodeableConcept>
    </extension>
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-befundungsprozedur" />
    <version value="2025.0.0" />
    <name value="MII_PR_Bildgebung_Radiologische_Befundungsprozedur">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="MII_PR_Imaging_Radiological_Readprocedure" />
            </extension>
        </extension>
    </name>
    <title value="MII PR Bildgebung Radiologische Befundungsprozedur">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="MII PR Imaging Radiological Readprocedure" />
            </extension>
        </extension>
    </title>
    <status value="active" />
    <date value="2025-01-01" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Diese Profil beschreibt die radiologische Befundungsprozedur. Es legt fest, dass es sich hierbei um eine reine diagnostische Prozedur handelt">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="This FHIR resource profile specifically characterizes the radiological reading process." />
            </extension>
        </extension>
    </description>
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="Procedure" />
    <baseDefinition value="https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Procedure" />
    <derivation value="constraint" />
    <differential>
        <element id="Procedure.category">
            <path value="Procedure.category" />
            <min value="1" />
            <patternCodeableConcept>
                <coding>
                    <system value="http://snomed.info/sct" />
                    <code value="165197003" />
                </coding>
            </patternCodeableConcept>
        </element>
        <element id="Procedure.code">
            <path value="Procedure.code" />
            <definition value="ode aus OPS - Operationen- und Prozedurenschl&#252;ssel, SNOMED CT oder andere." />
        </element>
        <element id="Procedure.subject">
            <path value="Procedure.subject" />
            <short value="Person">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Person" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="person" />
                    </extension>
                </extension>
            </short>
            <definition value="Person, auf die sich die Befundungprozedur bezieht">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Person, auf die sich die Befundungprozedur bezieht" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="person, which this read procedure is about" />
                    </extension>
                </extension>
            </definition>
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
            </type>
        </element>
        <element id="Procedure.report">
            <path value="Procedure.report" />
            <short value="Bericht">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Bericht" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="report" />
                    </extension>
                </extension>
            </short>
            <definition value="Referenz auf den Bericht">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Referenz auf den Bericht" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="reference on the report" />
                    </extension>
                </extension>
            </definition>
            <min value="1" />
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-bildgebung-radiologische-befundungsprozedur",
    "extension":  [
        {
            "url": "https://www.medizininformatik-initiative.de/fhir/modul-meta/StructureDefinition/mii-ex-meta-license-codeable",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://hl7.org/fhir/spdx-license",
                        "code": "CC-BY-4.0",
                        "display": "Creative Commons Attribution 4.0 International"
                    }
                ]
            }
        }
    ],
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-befundungsprozedur",
    "version": "2025.0.0",
    "name": "MII_PR_Bildgebung_Radiologische_Befundungsprozedur",
    "_name": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "MII_PR_Imaging_Radiological_Readprocedure"
                    }
                ]
            }
        ]
    },
    "title": "MII PR Bildgebung Radiologische Befundungsprozedur",
    "_title": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "MII PR Imaging Radiological Readprocedure"
                    }
                ]
            }
        ]
    },
    "status": "active",
    "date": "2025-01-01",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Diese Profil beschreibt die radiologische Befundungsprozedur. Es legt fest, dass es sich hierbei um eine reine diagnostische Prozedur handelt",
    "_description": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "This FHIR resource profile specifically characterizes the radiological reading process."
                    }
                ]
            }
        ]
    },
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "Procedure",
    "baseDefinition": "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Procedure",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Procedure.category",
                "path": "Procedure.category",
                "min": 1,
                "patternCodeableConcept": {
                    "coding":  [
                        {
                            "code": "165197003",
                            "system": "http://snomed.info/sct"
                        }
                    ]
                }
            },
            {
                "id": "Procedure.code",
                "path": "Procedure.code",
                "definition": "ode aus OPS - Operationen- und Prozedurenschlüssel, SNOMED CT oder andere."
            },
            {
                "id": "Procedure.subject",
                "path": "Procedure.subject",
                "short": "Person",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Person"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "person"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Person, auf die sich die Befundungprozedur bezieht",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Person, auf die sich die Befundungprozedur bezieht"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "person, which this read procedure is about"
                                }
                            ]
                        }
                    ]
                },
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient"
                        ]
                    }
                ]
            },
            {
                "id": "Procedure.report",
                "path": "Procedure.report",
                "short": "Bericht",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Bericht"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "report"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Referenz auf den Bericht",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Referenz auf den Bericht"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "reference on the report"
                                }
                            ]
                        }
                    ]
                },
                "min": 1,
                "mustSupport": true
            }
        ]
    }
}

MII PR Bildgebung Radiologische Befundungsprozedur

FHIR	Datensatz	Erklaerung
Procedure	Bildgebung.Befundungsprozedur	Befundungsprozedur
Procedure.status	Bildgebung.Befundungsprozedur.Status	Status der Befundungsprozedur
Procedure.category	Bildgebung.Befundungsprozedur.Kategorie	Kategoriesierung der Befundungsprozedur
Procedure.code	Bildgebung.Befundungsprozedur.Code	Code
Procedure.subject	Bildgebung.Befundungsprozedur.Person	Person, auf die sich die Befundungsprozedur bezieht. Hier soll das MII KDS-Profil Person verwendet werden.
Procedure.peformed[x]	Bildgebung.Befundungsprozedur.Befundungszeit	Befundungszeit
Procedure.report	Bildgebung.Befundungsprozedur.Bericht	Referenz auf den Bericht

Suchparameter

Folgende Suchparameter sind für das Modul Bildgebung relevant, auch in Kombination:

Name	Definition	Type	Expectation
_id	http://hl7.org/fhir/SearchParameter/Resource-id	token	SHALL
_lastUpdated	http://hl7.org/fhir/SearchParameter/Resource-lastUpdated	date	SHALL
_profile	http://hl7.org/fhir/SearchParameter/Resource-profile	uri	SHALL
_source	http://hl7.org/fhir/SearchParameter/Resource-source	uri	SHALL
based-on	http://hl7.org/fhir/SearchParameter/Procedure-based-on	reference	SHALL
status	http://hl7.org/fhir/SearchParameter/Procedure-status	token	SHALL
category	http://hl7.org/fhir/SearchParameter/Procedure-category	token	SHALL
code	http://hl7.org/fhir/SearchParameter/clinical-code	token	SHALL
patient	http://hl7.org/fhir/SearchParameter/clinical-patient	reference	SHALL
date	http://hl7.org/fhir/SearchParameter/clinical-date	date	SHALL
report	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/SearchParameter/mii-sp-bildgebung-read-proc-report	reference	SHALL

Beispiele

Beispiel einer Procedure-Ressource die sich auf die Befundung bezieht

{
    "resourceType": "Procedure",
    "id": "mii-exa-bildgebung-radiologische-befundungsprozedur",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-befundungsprozedur"
        ]
    },
    "category": {
        "coding":  [
            {
                "code": "165197003",
                "system": "http://snomed.info/sct"
            }
        ]
    },
    "status": "completed",
    "code": {
        "coding":  [
            {
                "code": "4261000179100",
                "system": "http://snomed.info/sct",
                "display": "Computed tomography imaging report (record artifact)"
            }
        ]
    },
    "subject": {
        "reference": "Patient/PatExample"
    },
    "performedDateTime": "2024-07-19T12:03:30+02:00",
    "report":  [
        {
            "reference": "DiagnosticReport/mii-exa-bildgebung-radiologischer-Befund"
        }
    ]
}