This page is part of the PanCareSurPass Project HL7 FHIR Implementation Guide (v0.1.0: QA Preview) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

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Resource Profile: Procedure: Surgery

This profile defines how to represent Procedures in FHIR for describing a set of Surgery data required by the PanCareSurPass algorithm to generate the care plan. It is used also to provide inforamtion about shunt, amputation, and other procedures

Usage:

• Use this Resource Profile: Bundle: Survivor Passport
• Refer to this Resource Profile: Bundle: Survivor Passport

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
text		0..1	Narrative	Textual description of the surgical procedure
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sacrifiedOrgan		0..1	CodeableConcept	Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
identifier		0..*	Identifier	External Identifiers for this surgical procedure
partOf		0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
category		1..1	CodeableConcept	Classification of the procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
code		0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject	S	1..1	Reference(Patient: PCSP)	Who the procedure was performed on
performed[x]		1..1	dateTime	When the procedure was performed Slice: Unordered, Open by type:$this
performedDateTime		1..1	dateTime	Date of the surgical procedure
location		0..1	Reference(Location: PCSP)	Where the procedure happened
reasonReference	S	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite		0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
laterality		0..1	CodeableConcept	Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
valueCodeableConcept		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice		0..*	BackboneElement	Implanted or removed device
action		0..1	CodeableConcept	Kind of change to device Binding: Surgical Actions (extensible)
manipulated		1..1	Reference(Device)	Device manipulated
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Procedure.code	extensible	SurgicalProcedureTypeVs
Procedure.bodySite	extensible	AffectedOrganVs
Procedure.bodySite.extension:laterality.valueCodeableConcept	required	LateralityQualifierVS
Procedure.focalDevice.action	extensible	SurgicalActionVs
Procedure.usedCode	extensible	ProsthesisTypeVs

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
text		0..1	Narrative	Textual description of the surgical procedure
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sacrifiedOrgan		0..1	CodeableConcept	Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this surgical procedure
partOf	Σ	0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
category	Σ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
code	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject	SΣ	1..1	Reference(Patient: PCSP)	Who the procedure was performed on
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	1..1	dateTime	Date of the surgical procedure
location	Σ	0..1	Reference(Location: PCSP)	Where the procedure happened
reasonReference	SΣ	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
laterality		0..1	CodeableConcept	Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
Slices for value[x]		1..1	CodeableConcept	Value of extension Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice		0..*	BackboneElement	Implanted or removed device
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: Surgical Actions (extensible)
manipulated		1..1	Reference(Device)	Device manipulated
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.status	required	EventStatus
Procedure.category	example	Pattern: SNOMED CT code 387713003
Procedure.code	extensible	SurgicalProcedureTypeVs
Procedure.bodySite	extensible	AffectedOrganVs
Procedure.bodySite.extension:laterality.value[x]:valueCodeableConcept	required	LateralityQualifierVS
Procedure.focalDevice.action	extensible	SurgicalActionVs
Procedure.usedCode	extensible	ProsthesisTypeVs

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Textual description of the surgical procedure
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sacrifiedOrgan		0..1	CodeableConcept	Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this surgical procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject	SΣ	1..1	Reference(Patient: PCSP)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	1..1	dateTime	Date of the surgical procedure
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location: PCSP)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	SΣ	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
laterality		0..1	CodeableConcept	Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
Slices for value[x]		1..1	CodeableConcept	Value of extension Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Implanted or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: Surgical Actions (extensible)
manipulated		1..1	Reference(Device)	Device manipulated
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	Pattern: SNOMED CT code 387713003
Procedure.code	extensible	SurgicalProcedureTypeVs
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.bodySite	extensible	AffectedOrganVs
Procedure.bodySite.extension:laterality.value[x]:valueCodeableConcept	required	LateralityQualifierVS
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	extensible	SurgicalActionVs
Procedure.usedCode	extensible	ProsthesisTypeVs

This structure is derived from Procedure

Summary

Mandatory: 4 elements (1 nested mandatory element)
Must-Support: 3 elements

Structures

This structure refers to these other structures:

• Procedure: Surgery (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-surgery-eu-pcsp)
• Patient: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Patient-eu-pcsp)
• Location: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Location-eu-pcsp)
• Condition: Primary Cancer (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Condition-primaryCancer-eu-pcsp)

Extensions

This structure refers to these extensions:

• http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan
• http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier

Slices

This structure defines the following Slices:

• The element Procedure.performed[x] is sliced based on the value of type:$this

Differential View

This structure is derived from Procedure

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
text		0..1	Narrative	Textual description of the surgical procedure
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sacrifiedOrgan		0..1	CodeableConcept	Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
identifier		0..*	Identifier	External Identifiers for this surgical procedure
partOf		0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status	S	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
category		1..1	CodeableConcept	Classification of the procedure Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
code		0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject	S	1..1	Reference(Patient: PCSP)	Who the procedure was performed on
performed[x]		1..1	dateTime	When the procedure was performed Slice: Unordered, Open by type:$this
performedDateTime		1..1	dateTime	Date of the surgical procedure
location		0..1	Reference(Location: PCSP)	Where the procedure happened
reasonReference	S	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite		0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
laterality		0..1	CodeableConcept	Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
valueCodeableConcept		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice		0..*	BackboneElement	Implanted or removed device
action		0..1	CodeableConcept	Kind of change to device Binding: Surgical Actions (extensible)
manipulated		1..1	Reference(Device)	Device manipulated
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Procedure.code	extensible	SurgicalProcedureTypeVs
Procedure.bodySite	extensible	AffectedOrganVs
Procedure.bodySite.extension:laterality.valueCodeableConcept	required	LateralityQualifierVS
Procedure.focalDevice.action	extensible	SurgicalActionVs
Procedure.usedCode	extensible	ProsthesisTypeVs

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
text		0..1	Narrative	Textual description of the surgical procedure
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sacrifiedOrgan		0..1	CodeableConcept	Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this surgical procedure
partOf	Σ	0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
category	Σ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
code	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject	SΣ	1..1	Reference(Patient: PCSP)	Who the procedure was performed on
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	1..1	dateTime	Date of the surgical procedure
location	Σ	0..1	Reference(Location: PCSP)	Where the procedure happened
reasonReference	SΣ	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
laterality		0..1	CodeableConcept	Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
Slices for value[x]		1..1	CodeableConcept	Value of extension Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
focalDevice		0..*	BackboneElement	Implanted or removed device
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: Surgical Actions (extensible)
manipulated		1..1	Reference(Device)	Device manipulated
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.status	required	EventStatus
Procedure.category	example	Pattern: SNOMED CT code 387713003
Procedure.code	extensible	SurgicalProcedureTypeVs
Procedure.bodySite	extensible	AffectedOrganVs
Procedure.bodySite.extension:laterality.value[x]:valueCodeableConcept	required	LateralityQualifierVS
Procedure.focalDevice.action	extensible	SurgicalActionVs
Procedure.usedCode	extensible	ProsthesisTypeVs

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure		0..*	Procedure	An action that is being or was performed on a patient
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Textual description of the surgical procedure
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sacrifiedOrgan		0..1	CodeableConcept	Sacrified organ URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan Binding: Sacrified Organs (surgery) (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this surgical procedure
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan | ServiceRequest)	A request for this procedure
partOf	Σ	0..*	Reference(Procedure: Surgery)	Reference to the parent surgery procedure
status	?!SΣ	1..1	code	preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required): A code specifying the state of the procedure.
statusReason	Σ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
category	Σ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code	Σ	0..1	CodeableConcept	Identification of the procedure. Binding: Surgical Procedure Type (extensible)
subject	SΣ	1..1	Reference(Patient: PCSP)	Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
Slices for performed[x]	Σ	1..1	dateTime	When the procedure was performed Slice: Unordered, Closed by type:$this
performed[x]:performedDateTime	Σ	1..1	dateTime	Date of the surgical procedure
recorder	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Who recorded the procedure
asserter	Σ	0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)	Person who asserts this procedure
performer	Σ	0..*	BackboneElement	The people who performed the procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
function	Σ	0..1	CodeableConcept	Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
actor	Σ	1..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)	The reference to the practitioner
onBehalfOf		0..1	Reference(Organization)	Organization the device or practitioner was acting for
location	Σ	0..1	Reference(Location: PCSP)	Where the procedure happened
reasonCode	Σ	0..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
reasonReference	SΣ	1..*	Reference(Condition: Primary Cancer)	The justification that the procedure was performed
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: Affected Organs (surgery) (extensible)
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
laterality		0..1	CodeableConcept	Laterality Qualifier URL: http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier"
Slices for value[x]		1..1	CodeableConcept	Value of extension Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept		1..1	CodeableConcept	Value of extension Binding: Laterality Qualifier Value Set (required)
coding	Σ	0..*	Coding	Code defined by a terminology system
text	Σ	0..1	string	Plain text representation of the concept
outcome	Σ	0..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
report		0..*	Reference(DiagnosticReport | DocumentReference | Composition)	Any report resulting from the procedure
complication		0..*	CodeableConcept	Complication following the procedure Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
complicationDetail		0..*	Reference(Condition)	A condition that is a result of the procedure
followUp		0..*	CodeableConcept	Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
note		0..*	Annotation	Additional information about the procedure
focalDevice		0..*	BackboneElement	Implanted or removed device
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
action		0..1	CodeableConcept	Kind of change to device Binding: Surgical Actions (extensible)
manipulated		1..1	Reference(Device)	Device manipulated
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: Prosthesis Type (extensible)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	Pattern: SNOMED CT code 387713003
Procedure.code	extensible	SurgicalProcedureTypeVs
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.bodySite	extensible	AffectedOrganVs
Procedure.bodySite.extension:laterality.value[x]:valueCodeableConcept	required	LateralityQualifierVS
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	extensible	SurgicalActionVs
Procedure.usedCode	extensible	ProsthesisTypeVs

This structure is derived from Procedure

Summary

Mandatory: 4 elements (1 nested mandatory element)
Must-Support: 3 elements

Structures

This structure refers to these other structures:

• Procedure: Surgery (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-surgery-eu-pcsp)
• Patient: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Patient-eu-pcsp)
• Location: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Location-eu-pcsp)
• Condition: Primary Cancer (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Condition-primaryCancer-eu-pcsp)

Extensions

This structure refers to these extensions:

• http://hl7.eu/fhir/ig/pcsp/StructureDefinition/surgery-sacrifiedOrgan
• http://hl7.eu/fhir/ig/pcsp/StructureDefinition/mcode-laterality-qualifier

Slices

This structure defines the following Slices:

• The element Procedure.performed[x] is sliced based on the value of type:$this

Other representations of profile: CSV, Excel, Schematron