MII IG Kerndatensatz-Modul Bildgebung
2027.0.0-ballot.1 -
Germany
MII IG Kerndatensatz-Modul Bildgebung
2027.0.0-ballot.1 -
Germany
MII IG Kerndatensatz-Modul Bildgebung - Downloaded Version 2027.0.0-ballot.1 See the Directory of published versions
| Official URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-bildgebungsprozedur | Version: 2027.0.0-ballot.1 | |||
| Active as of 2026-09-15 | Computable Name: MII_PR_Bildgebung_Bildgebungsprozedur | |||
The profile describes a advisory for medical care.
This Procedure resource is used to record the imaging procedure. It offers the possibility to use the contrast administration both with the diagnostic report and with the DICOM metadata.
The mapping of the dataset elements to this profile is documented in the Logical Model Bildgebung.
Examples
Example of a Procedure resource relating to the imaging:
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots, and their representations.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Procedure |
C | 0..* | MII_PR_Prozedur_Procedure | An action that is being or was performed on a patient Constraints: proc-mii-1 |
  id |
SΣ | 0..1 | id | Logical id of this artifact |
  meta |
SΣ | 0..1 | Meta | Metadata about the resource |
 source |
SΣ | 0..1 | uri | Identifies where the resource comes from |
 profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension |
S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
  extension:Dokumentationsdatum |
S | 0..1 | (Complex) | Dokumentationsdatum URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum |
  extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum" |
 value[x] |
S | 1..1 | dateTime | Value of extension |
 extension:durchfuehrungsabsicht |
S | 0..1 | (Complex) | Durchführungsabsicht URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht |
 extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||
| url |
S | 1..1 | uri | "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht" |
 value[x] |
S | 1..1 | Coding | Value of extension Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (required) |
| 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 |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
 basedOn |
SΣ | 1..* | Reference(MII PR Bildgebung Anforderung Bildgebung) | Basiert auf |
| status |
?!SΣ | 1..1 | code | Status Binding: EventStatus (required): A code specifying the state of the procedure. |
| category |
SΣ | 1..1 | CodeableConcept | Kategorie 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 pattern:$this |
 coding:All Slices |
Content/Rules for all slices | |||
 system |
SΣ | 1..1 | uri | Identity of the terminology system |
 code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Prozedur OPS Kategorien [SNOMED CT] (preferred) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
 version |
1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| system |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 |
| code |
SΣC | 1..1 | CodeableConcept | Code Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1 |
| Slices for coding |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
| coding:All Slices |
Content/Rules for all slices | |||
| system |
SΣ | 1..1 | uri | Identity of the terminology system |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| coding:ops |
SΣ | 0..1 | CodingOPS | Operationen- und Prozedurenschlüssel (OPS) Code Binding: MII VS Prozedur OPS (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
 Slices for extension |
Content/Rules for all slices | |||
 extension:Seitenlokalisation |
S | 0..1 | (Complex) | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation |
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/seitenlokalisation" |
| value[x] |
S | 1..1 | Coding | Value of extension Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION  (required) |
| system |
SΣ | 1..1 | uri | Identity of the terminology system |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops |
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") |
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 |
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Bildgebung ImagingProcedure Code SCT (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| version |
0..1 | string | Version of the system - if relevant | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| 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 |
| coding:loinc |
SΣ | 0..1 | Coding | LOINC Code Binding: LOINC loinc-rsna-radiology-playbook (required) Required Pattern: At least the following |
| 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://loinc.org | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
0..1 | code | Symbol in syntax defined by the system | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| subject |
SΣ | 1..1 | Reference(Patient) | Person |
| reference |
SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug) |
| reference |
SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| Slices for performed[x] |
SΣ | 1..1 | Durchführungsdatum Slice: Unordered, Closed by type:$this | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed |
| performed[x]:performedPeriod |
SΣ | 0..1 | Period | Durchführungszeitraum |
| bodySite |
SΣ | 0..* | CodeableConcept | Körperstelle Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| Slices for extension |
Content/Rules for all slices | |||
| extension:bodySite |
0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system |
| coding:snomed-ct |
SΣ | 0..1 | Coding | SNOMED CT Code |
| system |
SΣ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct |
| version |
SΣ | 0..1 | string | Version of the system - if relevant |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| note |
S | 0..* | Annotation | Hinweis |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| ops-regex | warning | Procedure.code.coding:ops.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt |
matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')
|
| proc-mii-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden |
code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
|
| sct-ops-1 | error | Procedure.code | Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden. |
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
0..* | MII_PR_Prozedur_Procedure | An action that is being or was performed on a patient | |
| basedOn |
S | 1..* | Reference(MII PR Bildgebung Anforderung Bildgebung) | Basiert auf |
| category |
1..1 | CodeableConcept | Kategorie | |
| coding |
1..* | Coding | Code defined by a terminology system | |
| system |
S | 1..1 | uri | Identity of the terminology system |
| code |
S | 1..1 | code | Symbol in syntax defined by the system |
| Slices for coding |
Content/Rules for all slices | |||
| coding:sct |
0..1 | Coding | SNOMED CT Code Required Pattern: At least the following | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging (procedure) | |
| code |
1..1 | CodeableConcept | Code | |
| coding |
1..* | Coding | Code defined by a terminology system | |
| system |
S | 1..1 | uri | Identity of the terminology system |
| code |
S | 1..1 | code | Symbol in syntax defined by the system |
| Slices for coding |
Content/Rules for all slices | |||
| coding:sct |
0..1 | Coding | SNOMED CT Code Binding: MII VS Bildgebung ImagingProcedure Code SCT (required) | |
| coding:loinc |
S | 0..1 | Coding | LOINC Code Binding: LOINC loinc-rsna-radiology-playbook (required) Required Pattern: At least the following |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| subject |
1..1 | Reference(Patient) | Person | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.code.coding:sct | Base | required | MII VS Bildgebung ImagingProcedure Code SCT | 📦2027.0.0-ballot.1 | This IG |
| Procedure.code.coding:loinc | Base | required | LOINC loinc-rsna-radiology-playbook |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | MII_PR_Prozedur_Procedure | An action that is being or was performed on a patient Constraints: proc-mii-1 | ||||
| id |
SΣ | 0..1 | id | Logical id of this artifact | ||||
| meta |
SΣ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
SΣ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| extension:Dokumentationsdatum |
S | 0..1 | (Complex) | Dokumentationsdatum URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum" | ||||
| value[x] |
S | 1..1 | dateTime | Value of extension | ||||
| extension:durchfuehrungsabsicht |
S | 0..1 | (Complex) | Durchführungsabsicht URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||
| url |
S | 1..1 | uri | "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht" | ||||
| value[x] |
S | 1..1 | Coding | Value of extension Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (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 | |||||
| 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 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| 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 |
SΣ | 1..* | Reference(MII PR Bildgebung Anforderung Bildgebung) | Basiert auf | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | Status 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 |
SΣ | 1..1 | CodeableConcept | Kategorie 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 pattern:$this | ||||
| coding:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Prozedur OPS Kategorien [SNOMED CT] (preferred) Required Pattern: At least the following | ||||
| 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 Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701 | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system Fixed Value: Imaging (procedure) | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| code |
SΣC | 1..1 | CodeableConcept | Code Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1 | ||||
| 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 pattern:$this | ||||
| coding:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:ops |
SΣ | 0..1 | CodingOPS | Operationen- und Prozedurenschlüssel (OPS) Code Binding: MII VS Prozedur OPS (required) Required Pattern: At least the following | ||||
| 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 | |||||
| Slices for extension |
Content/Rules for all slices | |||||||
| extension:Seitenlokalisation |
S | 0..1 | (Complex) | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/seitenlokalisation" | ||||
| value[x] |
S | 1..1 | Coding | Value of extension Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (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 | |||||
| system |
SΣ | 1..1 | uri | Identity of the terminology system | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops | ||||
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") | ||||
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Bildgebung ImagingProcedure Code SCT (required) Required Pattern: At least the following | ||||
| 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 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:loinc |
SΣ | 0..1 | Coding | LOINC Code Binding: LOINC loinc-rsna-radiology-playbook (required) Required Pattern: At least the following | ||||
| 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://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
0..1 | code | Symbol in syntax defined by the system | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Person | ||||
| 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 | 0..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 | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug) | ||||
| 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 | 0..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 | ||||
| Slices for performed[x] |
SΣ | 1..1 | Durchführungsdatum Slice: Unordered, Closed by type:$this | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed | ||||
| performed[x]:performedPeriod |
SΣ | 0..1 | Period | Durchführungszeitraum | ||||
| 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 |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite |
SΣ | 0..* | CodeableConcept | Körperstelle Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| 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 | |||||
| extension:bodySite |
0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |||||
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system | ||||
| coding:snomed-ct |
SΣ | 0..1 | Coding | SNOMED CT Code | ||||
| 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 Required Pattern: http://snomed.info/sct | ||||
| version |
SΣ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| 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 |
S | 0..* | Annotation | Hinweis | ||||
| 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 | ||||||||
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| ops-regex | warning | Procedure.code.coding:ops.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt |
matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')
|
| proc-mii-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden |
code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
|
| sct-ops-1 | error | Procedure.code | Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden. |
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()
|
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
C | 0..* | MII_PR_Prozedur_Procedure | An action that is being or was performed on a patient Constraints: proc-mii-1 |
| id |
SΣ | 0..1 | id | Logical id of this artifact |
| meta |
SΣ | 0..1 | Meta | Metadata about the resource |
| source |
SΣ | 0..1 | uri | Identifies where the resource comes from |
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| extension:Dokumentationsdatum |
S | 0..1 | (Complex) | Dokumentationsdatum URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum |
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum" |
| value[x] |
S | 1..1 | dateTime | Value of extension |
| extension:durchfuehrungsabsicht |
S | 0..1 | (Complex) | Durchführungsabsicht URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht |
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||
| url |
S | 1..1 | uri | "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht" |
| value[x] |
S | 1..1 | Coding | Value of extension Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (required) |
| 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 |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn |
SΣ | 1..* | Reference(MII PR Bildgebung Anforderung Bildgebung) | Basiert auf |
| status |
?!SΣ | 1..1 | code | Status Binding: EventStatus (required): A code specifying the state of the procedure. |
| category |
SΣ | 1..1 | CodeableConcept | Kategorie 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 pattern:$this |
| coding:All Slices |
Content/Rules for all slices | |||
| system |
SΣ | 1..1 | uri | Identity of the terminology system |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Prozedur OPS Kategorien [SNOMED CT] (preferred) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| version |
1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| system |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 |
| code |
SΣC | 1..1 | CodeableConcept | Code Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1 |
| Slices for coding |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
| coding:All Slices |
Content/Rules for all slices | |||
| system |
SΣ | 1..1 | uri | Identity of the terminology system |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| coding:ops |
SΣ | 0..1 | CodingOPS | Operationen- und Prozedurenschlüssel (OPS) Code Binding: MII VS Prozedur OPS (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| Slices for extension |
Content/Rules for all slices | |||
| extension:Seitenlokalisation |
S | 0..1 | (Complex) | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation |
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/seitenlokalisation" |
| value[x] |
S | 1..1 | Coding | Value of extension Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) |
| system |
SΣ | 1..1 | uri | Identity of the terminology system |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops |
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") |
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 |
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Bildgebung ImagingProcedure Code SCT (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| version |
0..1 | string | Version of the system - if relevant | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| 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 |
| coding:loinc |
SΣ | 0..1 | Coding | LOINC Code Binding: LOINC loinc-rsna-radiology-playbook (required) Required Pattern: At least the following |
| 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://loinc.org | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
0..1 | code | Symbol in syntax defined by the system | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| subject |
SΣ | 1..1 | Reference(Patient) | Person |
| reference |
SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter |
SΣ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug) |
| reference |
SΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| Slices for performed[x] |
SΣ | 1..1 | Durchführungsdatum Slice: Unordered, Closed by type:$this | |
| performedDateTime |
dateTime | |||
| performedPeriod |
Period | |||
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed |
| performed[x]:performedPeriod |
SΣ | 0..1 | Period | Durchführungszeitraum |
| bodySite |
SΣ | 0..* | CodeableConcept | Körperstelle Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| Slices for extension |
Content/Rules for all slices | |||
| extension:bodySite |
0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system |
| coding:snomed-ct |
SΣ | 0..1 | Coding | SNOMED CT Code |
| system |
SΣ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct |
| version |
SΣ | 0..1 | string | Version of the system - if relevant |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| note |
S | 0..* | Annotation | Hinweis |
| Documentation for this format | ||||
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| ops-regex | warning | Procedure.code.coding:ops.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt |
matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')
|
| proc-mii-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden |
code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
|
| sct-ops-1 | error | Procedure.code | Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden. |
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()
|
Differential View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
0..* | MII_PR_Prozedur_Procedure | An action that is being or was performed on a patient | |
| basedOn |
S | 1..* | Reference(MII PR Bildgebung Anforderung Bildgebung) | Basiert auf |
| category |
1..1 | CodeableConcept | Kategorie | |
| coding |
1..* | Coding | Code defined by a terminology system | |
| system |
S | 1..1 | uri | Identity of the terminology system |
| code |
S | 1..1 | code | Symbol in syntax defined by the system |
| Slices for coding |
Content/Rules for all slices | |||
| coding:sct |
0..1 | Coding | SNOMED CT Code Required Pattern: At least the following | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
1..1 | string | Version of the system - if relevant Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701 | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Imaging (procedure) | |
| code |
1..1 | CodeableConcept | Code | |
| coding |
1..* | Coding | Code defined by a terminology system | |
| system |
S | 1..1 | uri | Identity of the terminology system |
| code |
S | 1..1 | code | Symbol in syntax defined by the system |
| Slices for coding |
Content/Rules for all slices | |||
| coding:sct |
0..1 | Coding | SNOMED CT Code Binding: MII VS Bildgebung ImagingProcedure Code SCT (required) | |
| coding:loinc |
S | 0..1 | Coding | LOINC Code Binding: LOINC loinc-rsna-radiology-playbook (required) Required Pattern: At least the following |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| subject |
1..1 | Reference(Patient) | Person | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.code.coding:sct | Base | required | MII VS Bildgebung ImagingProcedure Code SCT | 📦2027.0.0-ballot.1 | This IG |
| Procedure.code.coding:loinc | Base | required | LOINC loinc-rsna-radiology-playbook |
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | MII_PR_Prozedur_Procedure | An action that is being or was performed on a patient Constraints: proc-mii-1 | ||||
| id |
SΣ | 0..1 | id | Logical id of this artifact | ||||
| meta |
SΣ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
SΣ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
S | 0..* | Extension | Extension Slice: Unordered, Open by value:url | ||||
| extension:Dokumentationsdatum |
S | 0..1 | (Complex) | Dokumentationsdatum URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum" | ||||
| value[x] |
S | 1..1 | dateTime | Value of extension | ||||
| extension:durchfuehrungsabsicht |
S | 0..1 | (Complex) | Durchführungsabsicht URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Extension Slice: Unordered, Open by value:url | ||||||
| url |
S | 1..1 | uri | "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht" | ||||
| value[x] |
S | 1..1 | Coding | Value of extension Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (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 | |||||
| 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 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| 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 |
SΣ | 1..* | Reference(MII PR Bildgebung Anforderung Bildgebung) | Basiert auf | ||||
| partOf |
Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status |
?!SΣ | 1..1 | code | Status 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 |
SΣ | 1..1 | CodeableConcept | Kategorie 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 pattern:$this | ||||
| coding:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Prozedur OPS Kategorien [SNOMED CT] (preferred) Required Pattern: At least the following | ||||
| 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 Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701 | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 363679005 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system Fixed Value: Imaging (procedure) | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| code |
SΣC | 1..1 | CodeableConcept | Code Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure . Constraints: sct-ops-1 | ||||
| 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 pattern:$this | ||||
| coding:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:ops |
SΣ | 0..1 | CodingOPS | Operationen- und Prozedurenschlüssel (OPS) Code Binding: MII VS Prozedur OPS (required) Required Pattern: At least the following | ||||
| 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 | |||||
| Slices for extension |
Content/Rules for all slices | |||||||
| extension:Seitenlokalisation |
S | 0..1 | (Complex) | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..0 | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||||
| url |
S | 1..1 | uri | "http://fhir.de/StructureDefinition/seitenlokalisation" | ||||
| value[x] |
S | 1..1 | Coding | Value of extension Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (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 | |||||
| system |
SΣ | 1..1 | uri | Identity of the terminology system | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| system |
SΣ | 1..1 | uri | Canonische CodeSystem URL für OPS Fixed Value: http://fhir.de/CodeSystem/bfarm/ops | ||||
| version |
SΣ | 1..1 | string | Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") | ||||
| code |
SΣC | 1..1 | code | Der OPS-Code Constraints: ops-regex Example Einfacher OPS-Code: 5-470 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:sct |
SΣ | 0..1 | Coding | SNOMED CT Code Binding: MII VS Bildgebung ImagingProcedure Code SCT (required) Required Pattern: At least the following | ||||
| 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 | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| coding:loinc |
SΣ | 0..1 | Coding | LOINC Code Binding: LOINC loinc-rsna-radiology-playbook (required) Required Pattern: At least the following | ||||
| 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://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
0..1 | code | Symbol in syntax defined by the system | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Person | ||||
| 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 | 0..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 | ||||
| encounter |
SΣ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug) | ||||
| 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 | 0..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 | ||||
| Slices for performed[x] |
SΣ | 1..1 | Durchführungsdatum Slice: Unordered, Closed by type:$this | |||||
| performedDateTime |
dateTime | |||||||
| performedPeriod |
Period | |||||||
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed | ||||
| performed[x]:performedPeriod |
SΣ | 0..1 | Period | Durchführungszeitraum | ||||
| 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 |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite |
SΣ | 0..* | CodeableConcept | Körperstelle Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| 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 | |||||
| extension:bodySite |
0..1 | Reference(BodyStructure) | Target anatomic location or structure URL: http://hl7.org/fhir/StructureDefinition/bodySite | |||||
| Slices for coding |
SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:system | ||||
| coding:snomed-ct |
SΣ | 0..1 | Coding | SNOMED CT Code | ||||
| 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 Required Pattern: http://snomed.info/sct | ||||
| version |
SΣ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| 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 |
S | 0..* | Annotation | Hinweis | ||||
| 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 | ||||||||
| Id | Grade | Path(s) | Description | Expression |
| 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()
|
| ops-regex | warning | Procedure.code.coding:ops.code | In code sind nur gültige OPS-Codes ohne Zusätze erlaubt |
matches('^[1|3|5|6|8|9]-[a-zA-Z0-9]{3}([.][a-zA-Z0-9]{1,2})?$')
|
| proc-mii-1 | error | Procedure | Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden |
code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()
|
| sct-ops-1 | error | Procedure.code | Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden. |
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()
|
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