Operation - Procedure

Dieses Profil beschreibt eine Operation als Therapieoption innerhalb des nNGM-Projektes.

Name: "Profile_nNGM_Procedure_Operation" (Simplifier Link)

Canonical: http://uk-koeln.de/fhir/StructureDefinition/Procedure/nNGM/OP

Differential

lymphadenektomieS I0..1Extension(boolean)
episodeOfCareS I0..1Extension(Reference(EpisodeOfCare))
identifierΣ0..*Identifier
instantiatesCanonicalΣ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)
instantiatesUriΣ0..*uri
basedOnΣ I0..*Reference(CarePlan | ServiceRequest)
partOfΣ I0..*Reference(Procedure | Observation | MedicationAdministration)
statusS Σ ?!1..1codeBindingFixed Value
statusReasonΣ0..1CodeableConcept
categoryΣ0..1CodeableConcept
resektionS I0..1Extension(Complex)
artDesEingriffsS I0..1Extension(CodeableConcept)
seitenlokalisationS I0..1Extension(Coding)
systemΣ0..1uri
versionΣ0..1string
codeΣ0..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
performedDateTimedateTime
recorderΣ I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)
asserterΣ I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)
functionΣ0..1CodeableConcept
referenceΣ I0..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayS Σ1..1stringBinding
onBehalfOfI0..1Reference(Organization)
locationΣ I0..1Reference(Location)
reasonCodeS Σ0..1CodeableConceptBinding
reasonReferenceΣ I0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
codingΣ0..*Coding
textS Σ0..1string
outcomeΣ0..1CodeableConcept
reportI0..*Reference(DiagnosticReport | DocumentReference | Composition)
complication0..*CodeableConcept
complicationDetailI0..*Reference(Condition)
followUp0..*CodeableConcept
noteS0..*Annotation
action0..1CodeableConceptBinding
manipulatedI1..1Reference(Device)
usedReferenceI0..*Reference(Device | Medication | Substance)
usedCode0..*CodeableConcept


Erläuterungen

FHIR-Element Erklärung
Procedure.status Nur abgeschlossene Operationen sollten übermittelt werden
Procedure.code Eine kodierte Prozedur muss übermittelt werden, falls kein bestehender Code verfügbar ist, kann die NCIT-Kodierung verwendet werden
Procedure.subject Ein Bezug zum Patienten muss stets gegeben sein
Procedure.performer.actor.display Klassifizierung der Organisation, da externe Organisationen hier vorkommen können, zunächst nur als Freitext



Mapping Logischer Datensatz

FHIR-Element Logischer Datensatz
Operationsdatum Procedure.performedDateTime
DurchfuehrendeEinrichtung Procedure.performer.actor.display
Operationsmerkmale.OperativeIntention Procedure.reasonCode
Operationsmerkmale.ArtDesEingriffs Procedure.code.extension:artDesEingriffs
Lokalisation Procedure.bodySite
Seitenlokalisation Procedure.code.extension:seitenlokalisation
Resektion.Resektionsart Procedure.code.extension:resektion
Resektion.Resektionsstatus Procedure.code.extension:resektion
Ektomie Procedure.extension:lymphadenektomie
Bemerkungen Procedure.note



Bindings

FHIR Element ValueSets / NamingSystems
Procedure.status Fixed Value - EventStatus
Procedure.code.extension:resektion ValueSet_nNGM_Operation_ArtDerResektion
ValueSet_nNGM_Operation_Resektionsstatus
Procedure.code.extension:artDesEingriffs ValueSet_nNGM_Operation_ArtDesEingriffs
Procedure.code.coding.extension:seitenlokalisation KBV_VS_SFHIR_ICD_SEITENLOKALISATION
Procedure.performer.actor.display ValueSet_nNGM_Durchfuehrende_Einrichtung
Procedure.reasonCode ValueSet_nNGM_Operation_Intention
Procedure.bodySite ValueSet_nNGM_Operation_Lokalisation

Snapshot

lymphadenektomieS I0..1Extension(boolean)
episodeOfCareS I0..1Extension(Reference(EpisodeOfCare))
identifierΣ0..*Identifier
instantiatesCanonicalΣ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)
instantiatesUriΣ0..*uri
basedOnΣ I0..*Reference(CarePlan | ServiceRequest)
partOfΣ I0..*Reference(Procedure | Observation | MedicationAdministration)
statusS Σ ?!1..1codeBindingFixed Value
statusReasonΣ0..1CodeableConcept
categoryΣ0..1CodeableConcept
resektionS I0..1Extension(Complex)
artDesEingriffsS I0..1Extension(CodeableConcept)
seitenlokalisationS I0..1Extension(Coding)
systemΣ0..1uri
versionΣ0..1string
codeΣ0..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
performedDateTimedateTime
recorderΣ I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)
asserterΣ I0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)
functionΣ0..1CodeableConcept
referenceΣ I0..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayS Σ1..1stringBinding
onBehalfOfI0..1Reference(Organization)
locationΣ I0..1Reference(Location)
reasonCodeS Σ0..1CodeableConceptBinding
reasonReferenceΣ I0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)
codingΣ0..*Coding
textS Σ0..1string
outcomeΣ0..1CodeableConcept
reportI0..*Reference(DiagnosticReport | DocumentReference | Composition)
complication0..*CodeableConcept
complicationDetailI0..*Reference(Condition)
followUp0..*CodeableConcept
noteS0..*Annotation
action0..1CodeableConceptBinding
manipulatedI1..1Reference(Device)
usedReferenceI0..*Reference(Device | Medication | Substance)
usedCode0..*CodeableConcept


Abgleich der Kompabilität

  • Die Basisprofile Onkologie - HL7 Deutschland enthalten kein Profil für das Datenobjekt "Operation"

  • Das vorliegende Profil ist kompatibel zum FHIR-Profil "Operation" des DKTK falls:

    • Die Codes des ValueSet OPIntentionVS auf das ValueSet ValueSet_nNGM_Operation_Intention gemappt werden und diese Werte unter .reasonCode abgebildet werden

Beispiel

{
    "resourceType": "Procedure",
    "id": "ExampleProcedureOperation",
    "meta": {
        "profile":  [
            "http://uk-koeln.de/fhir/StructureDefinition/Procedure/nNGM/OP"
        ]
    },
    "extension":  [
        {
            "url": "http://hl7.org/fhir/StructureDefinition/workflow-episodeOfCare",
            "valueReference": {
                "reference": "EpisodeOfCare/ExampleEpisodeOfCareVersorgungsfall"
            }
        }
    ],
    "status": "completed",
    "code": {
        "extension":  [
            {
                "url": "http://uk-koeln.de/fhir/StructureDefinition/Extension/nNGM/OperationArtDesEingriffs",
                "valueCodeableConcept": {
                    "coding":  [
                        {
                            "system": "http://uk-koeln.de/fhir/CodeSystem/nNGM/OperationArtDesEingriffs",
                            "code": "Bilobektomie"
                        }
                    ]
                }
            },
            {
                "url": "http://uk-koeln.de/fhir/StructureDefinition/Extension/nNGM/OperationResektion",
                "extension":  [
                    {
                        "url": "resektionsart",
                        "valueCodeableConcept": {
                            "coding":  [
                                {
                                    "system": "http://uk-koeln.de/fhir/CodeSystem/nNGM/OperationArtResektion",
                                    "code": "Resektion des Primarius"
                                }
                            ]
                        }
                    },
                    {
                        "url": "resektionsstatus",
                        "valueCodeableConcept": {
                            "coding":  [
                                {
                                    "system": "http://loinc.org",
                                    "code": "LA26542-3"
                                }
                            ]
                        }
                    }
                ]
            }
        ],
        "coding":  [
            {
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/seitenlokalisation",
                        "valueCoding": {
                            "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION",
                            "code": "L",
                            "display": "links"
                        }
                    }
                ],
                "system": "http://ncicb.nci.nih.gov/xml/owl/EVS/Thesaurus.owl",
                "code": "C15329",
                "display": "Surgical Procedure"
            }
        ]
    },
    "subject": {
        "reference": "Patient/ExamplePatientPatient"
    },
    "performedDateTime": "2021-01-01",
    "performer":  [
        {
            "actor": {
                "display": "Niedergelassene Einrichtung - Chirurgie"
            }
        }
    ],
    "reasonCode": {
        "coding":  [
            {
                "system": "http://uk-koeln.de/fhir/CodeSystem/nNGM/IntentionTherapie",
                "code": "Kurativ"
            }
        ]
    },
    "bodySite":  [
        {
            "coding":  [
                {
                    "system": "http://uk-koeln.de/fhir/CodeSystem/nNGM/OperationLokalisation",
                    "code": "Lunge"
                }
            ]
        }
    ]
}