{ "resourceType": "StructureDefinition", "id": "CancerProcedure", "meta": { "versionId": "2", "lastUpdated": "2016-11-27T05:38:32.674+00:00" }, "url": "http://icecoldfhirga.tech/baseDstu3/StructureDefinition/CancerProcedure", "identifier": [ { "system": "http://clinfhir.com", "value": "author" } ], "name": "CancerProcedure", "status": "active", "experimental": true, "publisher": "http://icecoldfhirga.tech/baseDstu3/", "kind": "resource", "abstract": false, "snapshot": { "element": [ { "id": "Procedure", "path": "Procedure", "short": "An action that is being or was performed on a patient", "definition": "An action that is or was performed on a patient. This can be a physical intervention like an operation, or less invasive like counseling or hypnotherapy.", "min": 0, "max": "*", "type": [ { "code": "DomainResource" } ], "constraint": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-expression", "valueString": "reasonNotPerformed.empty() or notPerformed = 'true'" } ], "key": "pro-1", "severity": "error", "human": "Reason not performed is only permitted if notPerformed indicator is true", "xpath": "not(exists(f:reasonNotPerformed)) or f:notPerformed/@value=true()" } ], "mapping": [ { "identity": "rim", "map": "Procedure[moodCode=EVN]" }, { "identity": "w5", "map": "clinical.general" } ] }, { "id": "Procedure.id", "path": "Procedure.id", "definition": "Id", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "code": "id" } ] }, { "id": "Procedure.meta", "path": "Procedure.meta", "definition": "The meta element", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ] }, { "id": "Procedure.text", "path": "Procedure.text", "definition": "Narrative", "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "*" }, "type": [ { "code": "Narrative" } ] }, { "id": "Procedure.identifier", "path": "Procedure.identifier", "short": "External Identifiers for this procedure", "definition": "This records identifiers associated with this procedure that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation).", "requirements": "Need to allow connection to a wider workflow.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "Some combination of ORC-2 / ORC-3 / OBR-2 / OBR-3 / IPC-1 / IPC-2 / IPC-3 / IPC-4" }, { "identity": "rim", "map": ".id" }, { "identity": "w5", "map": "id" } ] }, { "id": "Procedure.subject", "path": "Procedure.subject", "short": "Who the procedure was performed on", "definition": "The person, animal or group on which the procedure was performed.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Group" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PID-3" }, { "identity": "rim", "map": ".participation[typeCode=SBJ].role" }, { "identity": "w5", "map": "who.focus" } ] }, { "id": "Procedure.status", "path": "Procedure.status", "short": "in-progress | aborted | completed | entered-in-error", "definition": "A code specifying the state of the procedure. Generally this will be in-progress or completed state.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "A code specifying the state of the procedure.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-status" } } }, { "id": "Procedure.category", "path": "Procedure.category", "short": "Classification of the procedure", "definition": "A code that classifies the procedure for searching, sorting and display purposes (e.g. \"Surgical Procedure\").", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "A code that classifies a procedure for searching, sorting and display purposes.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-category" } }, "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" } ] }, { "id": "Procedure.code", "path": "Procedure.code", "short": "Identification of the procedure", "definition": "The specific procedure that is performed. Use text if the exact nature of the procedure cannot be coded (e.g. \"Laparoscopic Appendectomy\").", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "preferred", "description": "A code to identify a specific procedure .", "valueSetUri": "http://hl7.org/fhir/ValueSet/uslab-obs-codedresults" }, "mapping": [ { "identity": "v2", "map": "OBR-44/OBR-45" }, { "identity": "rim", "map": ".code" }, { "identity": "w5", "map": "class" } ] }, { "id": "Procedure.notPerformed", "path": "Procedure.notPerformed", "short": "True if procedure was not performed as scheduled", "definition": "Set this to true if the record is saying that the procedure was NOT performed.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "defaultValueBoolean": false, "isModifier": true, "mapping": [ { "identity": "rim", "map": ".actionNegationInd" } ] }, { "id": "Procedure.reasonNotPerformed", "path": "Procedure.reasonNotPerformed", "short": "Reason procedure was not performed", "definition": "A code indicating why the procedure was not performed.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "condition": [ "pro-1" ], "binding": { "strength": "example", "description": "A code that identifies the reason a procedure was not performed.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-not-performed-reason" } }, "mapping": [ { "identity": "rim", "map": ".reason.Observation.value" } ] }, { "id": "Procedure.bodySite", "path": "Procedure.bodySite", "short": "Target body sites", "definition": "Detailed and structured anatomical location information. Multiple locations are allowed - e.g. multiple punch biopsies of a lesion.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "preferred", "description": "Codes describing anatomical locations. May include laterality.", "valueSetUri": "http://hl7.org/fhir/ValueSet/body-site" }, "mapping": [ { "identity": "v2", "map": "OBX-20" }, { "identity": "rim", "map": ".targetSiteCode" } ] }, { "id": "Procedure.reason[x]", "path": "Procedure.reason[x]", "short": "Reason procedure performed", "definition": "The reason why the procedure was performed. This may be due to a Condition, may be coded entity of some type, or may simply be present as text.", "comments": "e.g. endoscopy for dilatation and biopsy, combination diagnosis and therapeutic.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" } ], "isSummary": true, "binding": { "strength": "example", "description": "A code that identifies the reason a procedure is required.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-reason" } }, "mapping": [ { "identity": "rim", "map": ".reasonCode" } ] }, { "id": "Procedure.performer", "path": "Procedure.performer", "short": "The people who performed the procedure", "definition": "Limited to 'real' people rather than equipment.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".participation[typeCode=PFM]" } ] }, { "id": "Procedure.performer.actor", "path": "Procedure.performer.actor", "short": "The reference to the practitioner", "definition": "The practitioner who was involved in the procedure.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Organization" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "ORC-19/PRT-5" }, { "identity": "rim", "map": ".role" }, { "identity": "w5", "map": "who.actor" } ] }, { "id": "Procedure.performer.role", "path": "Procedure.performer.role", "short": "The role the actor was in", "definition": "For example: surgeon, anaethetist, endoscopist.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "A code that identifies the role of a performer of the procedure.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/performer-role" } }, "mapping": [ { "identity": "v2", "map": "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" }, { "identity": "rim", "map": ".functionCode" } ] }, { "id": "Procedure.performed[x]", "path": "Procedure.performed[x]", "short": "Date/Period the procedure was performed", "definition": "The date(time)/period over which the procedure was performed. Allows a period to support complex procedures that span more than one date, and also allows for the length of the procedure to be captured.", "min": 0, "max": "1", "type": [ { "code": "dateTime" }, { "code": "Period" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "OBR-7" }, { "identity": "rim", "map": ".effectiveTime" }, { "identity": "w5", "map": "when.done" } ] }, { "id": "Procedure.encounter", "path": "Procedure.encounter", "short": "The encounter associated with the procedure", "definition": "The encounter during which the procedure was performed.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "isSummary": true, "mapping": [ { "identity": "v2", "map": "PV1-19" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" }, { "identity": "w5", "map": "context" } ] }, { "id": "Procedure.location", "path": "Procedure.location", "short": "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.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" } ], "isSummary": true, "mapping": [ { "identity": "w5", "map": "where" } ] }, { "id": "Procedure.outcome", "path": "Procedure.outcome", "short": "The result of procedure", "definition": "The outcome of the procedure - did it resolve reasons for the procedure being performed?", "comments": "If outcome contains narrative text only, it can be captured using the CodeableConcept.text.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "example", "description": "An outcome of a procedure - whether it was resolved or otherwise.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-outcome" } }, "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=OUT].target.text" } ] }, { "id": "Procedure.report", "path": "Procedure.report", "short": "Any report resulting from the procedure", "definition": "This could be a histology result, pathology report, surgical report, etc..", "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.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport" } ], "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN]" } ] }, { "id": "Procedure.complication", "path": "Procedure.complication", "short": "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.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Codes describing complications that resulted from a procedure.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/condition-code" } }, "mapping": [ { "identity": "rim", "map": "Need specialization of OUT for this." } ] }, { "id": "Procedure.followUp", "path": "Procedure.followUp", "short": "Instructions for follow up", "definition": "If the procedure required specific follow up - e.g. removal of sutures. The followup may be represented as a simple note, or could potentially be more complex in which case the CarePlan resource can be used.", "min": 0, "max": "*", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Specific follow up required for a procedure e.g. removal of sutures.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/procedure-followup" } }, "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=ACT, moodCode=INT].code" } ] }, { "id": "Procedure.request", "path": "Procedure.request", "short": "A request for this procedure", "definition": "A reference to a resource that contains details of the request for this procedure.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/CarePlan" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/DiagnosticOrder" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ProcedureRequest" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/ReferralRequest" } ] }, { "id": "Procedure.notes", "path": "Procedure.notes", "short": "Additional information about the procedure", "definition": "Any other notes about the procedure. E.g. the operative notes.", "min": 0, "max": "*", "type": [ { "code": "Annotation" } ], "mapping": [ { "identity": "v2", "map": "NTE" }, { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value" } ] }, { "id": "Procedure.focalDevice", "path": "Procedure.focalDevice", "short": "Device changed in procedure", "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.", "min": 0, "max": "*", "type": [ { "code": "BackboneElement" } ] }, { "id": "Procedure.focalDevice.action", "path": "Procedure.focalDevice.action", "short": "Kind of change to device", "definition": "The kind of change that happened to the device during the procedure.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "required", "description": "A kind of change that happened to the device during the procedure.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/device-action" } } }, { "id": "Procedure.focalDevice.manipulated", "path": "Procedure.focalDevice.manipulated", "short": "Device that was changed", "definition": "The device that was manipulated (changed) during the procedure.", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Device" } ] }, { "id": "Procedure.used", "path": "Procedure.used", "short": "Items used during procedure", "definition": "Identifies medications, devices and any other substance used as part of the procedure.", "comments": "For devices actually implanted or removed, use Procedure.device.", "requirements": "Used for tracking contamination, etc.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Device" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Medication" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Substance" } ] } ] } }