This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v4.0.0: STU4) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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Resource Profile: Cancer-Related Surgical Procedure 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. If a procedure occurs that is NOT a surgical procedure, use the US Core Procedure profile.

Usage:

• Examples for this Resource Profile: Procedure/cancer-related-surgical-procedure-jenny-m and Procedure/cancer-related-surgical-procedure-lobectomy

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' mcode-reason-required: One of reasonCode or reasonReference SHALL be present
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
treatmentIntent	S	0..1	CodeableConcept	Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (extensible) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣC	1..1	code	(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
performed[x]	SΣC	0..1		(USCDI) When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) ele-1: All FHIR elements must have a @value or children
reasonReference	SΣ	0..*	Reference(US Core Condition Problems and Health Concerns Profile)	The justification that the procedure was performed ele-1: All FHIR elements must have a @value or children
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. ele-1: All FHIR elements must have a @value or children
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
locationQualifier	S	0..*	CodeableConcept	General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
lateralityQualifier	S	0..1	CodeableConcept	Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vs from this IG
Procedure.reasonCode	extensible	CancerDisorderVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vs from this IG
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
mcode-reason-required	warning	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
treatmentIntent	S	0..1	CodeableConcept	Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (extensible)
code		1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject		1..1	Reference(US Core Patient Profile)	(USCDI) Who the procedure was performed on
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible)
reasonReference	S	0..*	Reference(US Core Condition Problems and Health Concerns Profile)	The justification that the procedure was performed
bodySite	S	0..*	CodeableConcept	Target body sites
extension	S	0..*	Extension	Extension
Slices for extension				Content/Rules for all slices
locationQualifier	S	0..*	CodeableConcept	General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required)
lateralityQualifier	S	0..1	CodeableConcept	Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vs from this IG
Procedure.reasonCode	extensible	CancerDisorderVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vs from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
mcode-reason-required	warning	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' mcode-reason-required: One of reasonCode or reasonReference SHALL be present
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
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
treatmentIntent	S	0..1	CodeableConcept	Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this 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(US Core CarePlan Profile | US Core ServiceRequest Profile)	(USCDI) A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	1..1	code	(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
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	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SΣ	1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣC	0..1		(USCDI) When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
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	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible)
reasonReference	SΣ	0..*	Reference(US Core Condition Problems and Health Concerns Profile)	The justification that the procedure was performed
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
id		0..1	string	Unique id for inter-element referencing
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
locationQualifier	S	0..*	CodeableConcept	General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required)
lateralityQualifier	S	0..1	CodeableConcept	Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier 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	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	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vs from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	extensible	CancerDisorderVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vs from this IG
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
mcode-reason-required	warning	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()

This structure is derived from USCoreProcedureProfile

Summary

Must-Support: 8 elements

Structures

This structure refers to these other structures:

• US Core Condition Problems and Health Concerns Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent
• http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier
• http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier

Maturity: 3

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' mcode-reason-required: One of reasonCode or reasonReference SHALL be present
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
treatmentIntent	S	0..1	CodeableConcept	Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (extensible) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!SΣC	1..1	code	(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required) ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible) ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the procedure was performed on ele-1: All FHIR elements must have a @value or children
performed[x]	SΣC	0..1		(USCDI) When the procedure was performed ele-1: All FHIR elements must have a @value or children
performedDateTime			dateTime
reasonCode	SΣ	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible) ele-1: All FHIR elements must have a @value or children
reasonReference	SΣ	0..*	Reference(US Core Condition Problems and Health Concerns Profile)	The justification that the procedure was performed ele-1: All FHIR elements must have a @value or children
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. ele-1: All FHIR elements must have a @value or children
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
locationQualifier	S	0..*	CodeableConcept	General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
lateralityQualifier	S	0..1	CodeableConcept	Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required) ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vs from this IG
Procedure.reasonCode	extensible	CancerDisorderVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vs from this IG
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
mcode-reason-required	warning	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()

Differential View

This structure is derived from USCoreProcedureProfile

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient mcode-reason-required: One of reasonCode or reasonReference SHALL be present
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
treatmentIntent	S	0..1	CodeableConcept	Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (extensible)
code		1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject		1..1	Reference(US Core Patient Profile)	(USCDI) Who the procedure was performed on
reasonCode	S	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible)
reasonReference	S	0..*	Reference(US Core Condition Problems and Health Concerns Profile)	The justification that the procedure was performed
bodySite	S	0..*	CodeableConcept	Target body sites
extension	S	0..*	Extension	Extension
Slices for extension				Content/Rules for all slices
locationQualifier	S	0..*	CodeableConcept	General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required)
lateralityQualifier	S	0..1	CodeableConcept	Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier Binding: Laterality Qualifier Value Set (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vs from this IG
Procedure.reasonCode	extensible	CancerDisorderVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vs from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
mcode-reason-required	warning	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Procedure	C	0..*	USCoreProcedureProfile	An action that is being or was performed on a patient us-core-7: Performed SHALL be present if the status is 'completed' or 'in-progress' mcode-reason-required: One of reasonCode or reasonReference SHALL be present
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
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
treatmentIntent	S	0..1	CodeableConcept	Procedure Intent Extension URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent Binding: Procedure Intent Value Set (extensible)
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Identifiers for this 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(US Core CarePlan Profile | US Core ServiceRequest Profile)	(USCDI) A request for this procedure
partOf	Σ	0..*	Reference(Procedure | Observation | MedicationAdministration)	Part of referenced event
status	?!SΣC	1..1	code	(USCDI) preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown Binding: EventStatus (required)
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	0..1	CodeableConcept	Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
code	SΣ	1..1	CodeableConcept	(USCDI) Identification of the procedure Binding: Cancer-Related Surgical Procedure Value Set (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who the procedure was performed on
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
performed[x]	SΣC	0..1		(USCDI) When the procedure was performed
performedDateTime			dateTime S
performedPeriod			Period
performedString			string
performedAge			Age
performedRange			Range
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	0..*	CodeableConcept	Coded reason procedure performed Binding: Cancer Disorder Value Set (extensible)
reasonReference	SΣ	0..*	Reference(US Core Condition Problems and Health Concerns Profile)	The justification that the procedure was performed
bodySite	SΣ	0..*	CodeableConcept	Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
id		0..1	string	Unique id for inter-element referencing
Slices for extension	S	0..*	Extension	Extension Slice: Unordered, Open by value:url
locationQualifier	S	0..*	CodeableConcept	General location qualifier (excluding laterality) for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier Binding: Body Location Qualifier Value Set (required)
lateralityQualifier	S	0..1	CodeableConcept	Laterality qualifier for this bodySite URL: http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier 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	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	URI
Procedure.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Procedure.status	required	EventStatus http://hl7.org/fhir/ValueSet/event-status from the FHIR Standard
Procedure.statusReason	example	ProcedureNotPerformedReason(SNOMED-CT) http://hl7.org/fhir/ValueSet/procedure-not-performed-reason from the FHIR Standard
Procedure.category	example	ProcedureCategoryCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-category from the FHIR Standard
Procedure.code	extensible	CancerRelatedSurgicalProcedureVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-related-surgical-procedure-vs from this IG
Procedure.performer.function	example	ProcedurePerformerRoleCodes http://hl7.org/fhir/ValueSet/performer-role from the FHIR Standard
Procedure.reasonCode	extensible	CancerDisorderVS http://hl7.org/fhir/us/mcode/ValueSet/mcode-cancer-disorder-vs from this IG
Procedure.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site from the FHIR Standard
Procedure.outcome	example	ProcedureOutcomeCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-outcome from the FHIR Standard
Procedure.complication	example	Condition/Problem/DiagnosisCodes http://hl7.org/fhir/ValueSet/condition-code from the FHIR Standard
Procedure.followUp	example	ProcedureFollowUpCodes(SNOMEDCT) http://hl7.org/fhir/ValueSet/procedure-followup from the FHIR Standard
Procedure.focalDevice.action	preferred	ProcedureDeviceActionCodes http://hl7.org/fhir/ValueSet/device-action from the FHIR Standard
Procedure.usedCode	example	FHIRDeviceTypes http://hl7.org/fhir/ValueSet/device-kind from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
mcode-reason-required	warning	Procedure	One of reasonCode or reasonReference SHALL be present : reasonCode.exists() or reasonReference.exists()

This structure is derived from USCoreProcedureProfile

Summary

Must-Support: 8 elements

Structures

This structure refers to these other structures:

• US Core Condition Problems and Health Concerns Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-procedure-intent
• http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-body-location-qualifier
• http://hl7.org/fhir/us/mcode/StructureDefinition/mcode-laterality-qualifier

Maturity: 3

Other representations of profile: CSV, Excel, Schematron