共同資料模式實作指引(Common Data Model IG) - Local Development build (v1.0.0-Trial Use). See the Directory of published versions

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Resource Profile: Cancer-Related Surgical Procedure P1 Profile

A surgical action addressing a cancer condition. The scope of this profile has been narrowed to cancer-related procedures by constraining the reasonReference and reasonCode to cancer conditions, one of which is required.

Usage:

• Refer to this Resource Profile: Composition CRLF

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
identifier	S	1..*	Identifier	External Identifiers for this procedure
system	S	1..1	uri	The namespace for the identifier value Fixed Value: https://build.fhir.org/ig/HL7/fhir-mCODE-ig/
value	S	1..1	string	Cancer-Related Surgical Procedure
status	S	1..1	code	[preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown] Fixed Value: completed
statusReason	S	0..1	CodeableConcept	Reason for current status
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code		1..1	code	LF.noop
display	S	1..1	string	[原發部位未手術原因]
text		0..1	string	[原發部位未手術原因]
category	S	1..1	CodeableConcept	Classification of the procedure
Slices for coding	S	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:userSelected
coding:SurgicalProcedure		0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display	S	1..1	string	Representation defined by the system Fixed Value: Surgical procedure
userSelected	S	1..1	boolean	If this coding was chosen directly by the user
coding:MISurgery		0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.misurgery]
display	S	1..1	string	[微創手術]
userSelected	S	1..1	boolean	If this coding was chosen directly by the user
code	S	0..1	CodeableConcept	Identification of the procedure
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.optype_h]
display	S	1..1	string	[申報醫院原發部位手術方式]
text		0..1	string	[申報醫院原發部位手術方式]
subject	S	1..1	Reference(Cancer Patient)	Who the procedure was performed on
reference		1..1	string	患者 Resource Link
performed[x]	S	1..1	dateTime	原發部位最確切的手術切除日期。[LF.dop_mds]
reasonCode	S	1..*	CodeableConcept	Coded reason procedure performed
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.optype_o]
display	S	1..1	string	[外院原發部位手術方式]
text		0..1	string	[外院原發部位手術方式]
reasonReference	S	0..*	Reference(Condition-Primary Cancer | Secondary Cancer Condition Profile)	The justification that the procedure was performed
reference	S	1..1	string	Literal reference, Relative, internal or absolute URL
outcome	S	1..1	CodeableConcept	The result of procedure
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.smargin]
display	S	1..1	string	[原發部位手術邊緣]
text		0..1	string	[原發部位手術邊緣]
note		0..*	Annotation	原發部位手術切緣距離
text		1..1	markdown	原發部位手術切緣距離。[LF.smargin_d]
Documentation for this format

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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	SΣ	1..1	uri	The namespace for the identifier value Fixed Value: https://build.fhir.org/ig/HL7/fhir-mCODE-ig/
value	SΣ	1..1	string	Cancer-Related Surgical Procedure Example General: 123456
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. Fixed Value: completed
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	Σ	1..1	code	LF.noop
display	SΣ	1..1	string	[原發部位未手術原因]
text	Σ	0..1	string	[原發部位未手術原因]
category	SΣ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:userSelected
coding:SurgicalProcedure	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Surgical procedure
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
coding:MISurgery	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.misurgery]
display	SΣ	1..1	string	[微創手術]
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
code	SΣ	0..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.optype_h]
display	SΣ	1..1	string	[申報醫院原發部位手術方式]
text	Σ	0..1	string	[申報醫院原發部位手術方式]
subject	SΣ	1..1	Reference(Cancer Patient)	Who the procedure was performed on
reference	ΣC	1..1	string	患者 Resource Link
performed[x]	SΣ	1..1	dateTime	原發部位最確切的手術切除日期。[LF.dop_mds]
reasonCode	SΣ	1..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.optype_o]
display	SΣ	1..1	string	[外院原發部位手術方式]
text	Σ	0..1	string	[外院原發部位手術方式]
reasonReference	SΣ	0..*	Reference(Condition-Primary Cancer | Secondary Cancer Condition Profile)	The justification that the procedure was performed
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
outcome	SΣ	1..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.smargin]
display	SΣ	1..1	string	[原發部位手術邊緣]
text	Σ	0..1	string	[原發部位手術邊緣]
note		0..*	Annotation	原發部位手術切緣距離
text	Σ	1..1	markdown	原發部位手術切緣距離。[LF.smargin_d]
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.identifier.use	required	IdentifierUse
Procedure.status	required	Fixed Value: completed
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT)
Procedure.code	example	ProcedureCodes(SNOMEDCT)
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	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-4	error	Procedure	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-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

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	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	SΣ	1..1	uri	The namespace for the identifier value Fixed Value: https://build.fhir.org/ig/HL7/fhir-mCODE-ig/
value	SΣ	1..1	string	Cancer-Related Surgical Procedure Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
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 | Observation | MedicationAdministration)	Part of referenced event
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. Fixed Value: completed
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	LF.noop
display	SΣ	1..1	string	[原發部位未手術原因]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[原發部位未手術原因]
category	SΣ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:userSelected
coding:SurgicalProcedure	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Surgical procedure
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
coding:MISurgery	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.misurgery]
display	SΣ	1..1	string	[微創手術]
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	SΣ	0..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.optype_h]
display	SΣ	1..1	string	[申報醫院原發部位手術方式]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[申報醫院原發部位手術方式]
subject	SΣ	1..1	Reference(Cancer Patient)	Who the procedure was performed on
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	患者 Resource Link
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	1..1	dateTime	原發部位最確切的手術切除日期。[LF.dop_mds]
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)	Where the procedure happened
reasonCode	SΣ	1..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.optype_o]
display	SΣ	1..1	string	[外院原發部位手術方式]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[外院原發部位手術方式]
reasonReference	SΣ	0..*	Reference(Condition-Primary Cancer | Secondary Cancer Condition Profile)	The justification that the procedure was performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	SΣ	1..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.smargin]
display	SΣ	1..1	string	[原發部位手術邊緣]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[原發部位手術邊緣]
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	原發部位手術切緣距離
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	Σ	1..1	markdown	原發部位手術切緣距離。[LF.smargin_d]
focalDevice		0..*	BackboneElement	Manipulated, 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: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Procedure.identifier.use	required	IdentifierUse
Procedure.identifier.type	extensible	Identifier Type Codes
Procedure.status	required	Fixed Value: completed
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT)
Procedure.code	example	ProcedureCodes(SNOMEDCT)
Procedure.subject.type	extensible	ResourceType
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.reasonReference.type	extensible	ResourceType
Procedure.bodySite	example	SNOMEDCTBodyStructures
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes
Procedure.usedCode	example	FHIRDeviceTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Procedure

Summary

Mandatory: 9 elements (21 nested mandatory elements)
Must-Support: 37 elements
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

• Cancer Patient (https://standard-interoperability-lab.com/fhir/StructureDefinition/cancer-patient)
• Condition-Primary Cancer (https://standard-interoperability-lab.com/fhir/StructureDefinition/primary-cancer-condition)
• Secondary Cancer Condition Profile (https://standard-interoperability-lab.com/fhir/StructureDefinition/secondary-cancer-condition)

Slices

This structure defines the following Slices:

• The element Procedure.category.coding is sliced based on the value of value:userSelected

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
identifier	S	1..*	Identifier	External Identifiers for this procedure
system	S	1..1	uri	The namespace for the identifier value Fixed Value: https://build.fhir.org/ig/HL7/fhir-mCODE-ig/
value	S	1..1	string	Cancer-Related Surgical Procedure
status	S	1..1	code	[preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown] Fixed Value: completed
statusReason	S	0..1	CodeableConcept	Reason for current status
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code		1..1	code	LF.noop
display	S	1..1	string	[原發部位未手術原因]
text		0..1	string	[原發部位未手術原因]
category	S	1..1	CodeableConcept	Classification of the procedure
Slices for coding	S	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:userSelected
coding:SurgicalProcedure		0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display	S	1..1	string	Representation defined by the system Fixed Value: Surgical procedure
userSelected	S	1..1	boolean	If this coding was chosen directly by the user
coding:MISurgery		0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.misurgery]
display	S	1..1	string	[微創手術]
userSelected	S	1..1	boolean	If this coding was chosen directly by the user
code	S	0..1	CodeableConcept	Identification of the procedure
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.optype_h]
display	S	1..1	string	[申報醫院原發部位手術方式]
text		0..1	string	[申報醫院原發部位手術方式]
subject	S	1..1	Reference(Cancer Patient)	Who the procedure was performed on
reference		1..1	string	患者 Resource Link
performed[x]	S	1..1	dateTime	原發部位最確切的手術切除日期。[LF.dop_mds]
reasonCode	S	1..*	CodeableConcept	Coded reason procedure performed
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.optype_o]
display	S	1..1	string	[外院原發部位手術方式]
text		0..1	string	[外院原發部位手術方式]
reasonReference	S	0..*	Reference(Condition-Primary Cancer | Secondary Cancer Condition Profile)	The justification that the procedure was performed
reference	S	1..1	string	Literal reference, Relative, internal or absolute URL
outcome	S	1..1	CodeableConcept	The result of procedure
coding	S	0..*	Coding	Code defined by a terminology system
system	S	1..1	uri	健保資料網址
code	S	1..1	code	[LF.smargin]
display	S	1..1	string	[原發部位手術邊緣]
text		0..1	string	[原發部位手術邊緣]
note		0..*	Annotation	原發部位手術切緣距離
text		1..1	markdown	原發部位手術切緣距離。[LF.smargin_d]
Documentation for this format

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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	SΣ	1..1	uri	The namespace for the identifier value Fixed Value: https://build.fhir.org/ig/HL7/fhir-mCODE-ig/
value	SΣ	1..1	string	Cancer-Related Surgical Procedure Example General: 123456
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. Fixed Value: completed
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	Σ	1..1	code	LF.noop
display	SΣ	1..1	string	[原發部位未手術原因]
text	Σ	0..1	string	[原發部位未手術原因]
category	SΣ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:userSelected
coding:SurgicalProcedure	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Surgical procedure
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
coding:MISurgery	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.misurgery]
display	SΣ	1..1	string	[微創手術]
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
code	SΣ	0..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.optype_h]
display	SΣ	1..1	string	[申報醫院原發部位手術方式]
text	Σ	0..1	string	[申報醫院原發部位手術方式]
subject	SΣ	1..1	Reference(Cancer Patient)	Who the procedure was performed on
reference	ΣC	1..1	string	患者 Resource Link
performed[x]	SΣ	1..1	dateTime	原發部位最確切的手術切除日期。[LF.dop_mds]
reasonCode	SΣ	1..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.optype_o]
display	SΣ	1..1	string	[外院原發部位手術方式]
text	Σ	0..1	string	[外院原發部位手術方式]
reasonReference	SΣ	0..*	Reference(Condition-Primary Cancer | Secondary Cancer Condition Profile)	The justification that the procedure was performed
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
outcome	SΣ	1..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
coding	SΣ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	健保資料網址
code	SΣ	1..1	code	[LF.smargin]
display	SΣ	1..1	string	[原發部位手術邊緣]
text	Σ	0..1	string	[原發部位手術邊緣]
note		0..*	Annotation	原發部位手術切緣距離
text	Σ	1..1	markdown	原發部位手術切緣距離。[LF.smargin_d]
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.identifier.use	required	IdentifierUse
Procedure.status	required	Fixed Value: completed
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT)
Procedure.code	example	ProcedureCodes(SNOMEDCT)
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Procedure	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Procedure	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-4	error	Procedure	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-5	error	Procedure	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Procedure	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

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	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	External Identifiers for this procedure
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	SΣ	1..1	uri	The namespace for the identifier value Fixed Value: https://build.fhir.org/ig/HL7/fhir-mCODE-ig/
value	SΣ	1..1	string	Cancer-Related Surgical Procedure Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
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 | Observation | MedicationAdministration)	Part of referenced event
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. Fixed Value: completed
statusReason	SΣ	0..1	CodeableConcept	Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	LF.noop
display	SΣ	1..1	string	[原發部位未手術原因]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[原發部位未手術原因]
category	SΣ	1..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:userSelected
coding:SurgicalProcedure	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 387713003
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Surgical procedure
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
coding:MISurgery	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.misurgery]
display	SΣ	1..1	string	[微創手術]
userSelected	SΣ	1..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	SΣ	0..1	CodeableConcept	Identification of the procedure Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.optype_h]
display	SΣ	1..1	string	[申報醫院原發部位手術方式]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[申報醫院原發部位手術方式]
subject	SΣ	1..1	Reference(Cancer Patient)	Who the procedure was performed on
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	患者 Resource Link
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣ	1..1	dateTime	原發部位最確切的手術切除日期。[LF.dop_mds]
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)	Where the procedure happened
reasonCode	SΣ	1..*	CodeableConcept	Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.optype_o]
display	SΣ	1..1	string	[外院原發部位手術方式]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[外院原發部位手術方式]
reasonReference	SΣ	0..*	Reference(Condition-Primary Cancer | Secondary Cancer Condition Profile)	The justification that the procedure was performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
bodySite	Σ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
outcome	SΣ	1..1	CodeableConcept	The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	健保資料網址
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	[LF.smargin]
display	SΣ	1..1	string	[原發部位手術邊緣]
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	[原發部位手術邊緣]
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	原發部位手術切緣距離
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
author[x]	Σ	0..1		Individual responsible for the annotation
authorReference			Reference(Practitioner | Patient | RelatedPerson | Organization)
authorString			string
time	Σ	0..1	dateTime	When the annotation was made
text	Σ	1..1	markdown	原發部位手術切緣距離。[LF.smargin_d]
focalDevice		0..*	BackboneElement	Manipulated, 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: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
manipulated		1..1	Reference(Device)	Device that was changed
usedReference		0..*	Reference(Device | Medication | Substance)	Items used during procedure
usedCode		0..*	CodeableConcept	Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Procedure.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Procedure.identifier.use	required	IdentifierUse
Procedure.identifier.type	extensible	Identifier Type Codes
Procedure.status	required	Fixed Value: completed
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT)
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT)
Procedure.code	example	ProcedureCodes(SNOMEDCT)
Procedure.subject.type	extensible	ResourceType
Procedure.performer.function	example	ProcedurePerformerRoleCodes
Procedure.reasonCode	example	ProcedureReasonCodes
Procedure.reasonReference.type	extensible	ResourceType
Procedure.bodySite	example	SNOMEDCTBodyStructures
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT)
Procedure.complication	example	Condition/Problem/DiagnosisCodes
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes
Procedure.usedCode	example	FHIRDeviceTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Procedure

Summary

Mandatory: 9 elements (21 nested mandatory elements)
Must-Support: 37 elements
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

• Cancer Patient (https://standard-interoperability-lab.com/fhir/StructureDefinition/cancer-patient)
• Condition-Primary Cancer (https://standard-interoperability-lab.com/fhir/StructureDefinition/primary-cancer-condition)
• Secondary Cancer Condition Profile (https://standard-interoperability-lab.com/fhir/StructureDefinition/secondary-cancer-condition)

Slices

This structure defines the following Slices:

• The element Procedure.category.coding is sliced based on the value of value:userSelected