MII IG Kerndatensatz-Modul Onkologie
2027.0.0-ballot.1 - Germany

This page is part of the MII IG Kerndatensatz-Modul Onkologie (v2027.0.0-ballot.1: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Ressourcenprofil: MII PR Onkologie Operation

Offizielle URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-operation Version: 2027.0.0-ballot.1
Active Stand: 2026-09-15 Maschinenlesbarer Name: MII_PR_Onko_Operation

Operation nach OPS inklusive Intention, Datum und Komplikationen:

Dieses Profil beschreibt eine Operation in der Onkologie.

  • Das Operationsprofil für die Onkologie ist vom Prozedurenmodul der MII abgeleitet und für oBDS-Inhalten zusätzlich ausspezifiziert. https://simplifier.net/guide/mii-ig-modul-prozedur-2024-de/MIIIGModulProzedur/TechnischeImplementierung/FHIRProfile/Prozedur-Procedure.page.md?version=current

Kategorie und Code

  • Die MII-Prozedur empfiehlt die Abbildung der Kategorie mittels der in SNOMED übertragenen OPS-Hauptkategorien (https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/ValueSet/procedures-category-sct) , wobei der SNOMED-Code 38771300 der OPS-Kategorie "5 - Operationen" entspricht. Laut oBDS kann hier aber in begründeten Fällen auch ein andere Kodierung (z.B. 103693007 für "1 - Diagnostische Maßnahmen") eigetragen werden. Die Kategorie wird aus diesem Grund nicht weiter eingeschränkt.
  • Die genaue Art der Prozedur wird im Feld Procedure.code kodiert. WICHTIG: Jede Procedure MUSS einen Code haben - entweder OPS oder SNOMED CT.
  • Primär SOLL ein OPS-Code verwendet werden. Wenn kein passender OPS-Code existiert, MUSS ein SNOMED CT Code gewählt werden.
  • Pro Procedure-Ressource SOLL maximal ein OPS-Wert kodiert werden. Zusätzliche Prozeduren werden als einzelne Procedure-Ressourcen abgebildet.
  • Achtung: Innerhalb des KDS-Moduls Onkologie wird die übergeorndete MII-Prozedur auch für die Abbildung der Strahlen- und Systemischen/abwartenden Therapie genutzt. Für die Besondheiten bei Kategorien und Code - siehe Strahlentherapie:Procedure und Systemische Therapie: Procedure.

Mehrteilige Eingriffe und zusammenhängende Operationen

Bei komplexen onkologischen Eingriffen werden häufig mehrere operative Prozeduren in einer Sitzung durchgeführt. Da pro Procedure-Ressource nur ein OPS-Code kodiert werden sollte, werden zwei Modellierungsansätze unterstützt:

Ansatz 1: Übergeordnete Procedure mit allgemeinem Code

WICHTIG: Eine Procedure MUSS entweder einen OPS-Code ODER einen SNOMED CT Code haben. Wenn kein passender OPS-Code für die übergeordnete Procedure existiert, MUSS ein geeigneter SNOMED CT Code gewählt werden.

  1. Übergeordnete Procedure: Eine Haupt-Procedure mit allgemeinem SNOMED CT Code für die Lokation/Art des Eingriffs
    • Procedure.code: SNOMED CT Code (z.B. 86481000 "Laparotomy (procedure)")
    • Procedure.code.coding[ops]: Bleibt leer, da kein spezifischer OPS-Code existiert
    • Diese Procedure SOLLTE das MII_PR_Onko_Operation Profil erfüllen
    • Hinweis: Der SNOMED CT Code muss aus verfügbaren SNOMED CT Konzepten gewählt werden
  2. Detaillierte Teil-Procedures: Einzelne Procedure-Ressourcen für jeden spezifischen OPS-Code
    • Verknüpfung über Procedure.partOf zur übergeordneten Procedure
    • Jede mit ihrem spezifischen OPS-Code

Beispiel:

Procedure/haupteingriff (SNOMED: 176282005 "Resektion des Rektums")
├── Procedure/teileingriff1 (partOf → haupteingriff)
│   └── OPS: 5-484.35 "Rektumresektion mit Anastomose"
└── Procedure/teileingriff2 (partOf → haupteingriff)
    └── OPS: 5-469.21 "Andere Operationen am Darm"

Ansatz 2: Gleichberechtigte Procedures

Bei komplexen Tumoroperationen, wo die Hierarchie nicht eindeutig ist:

  1. Alle Procedures gleichberechtigt: Jede Procedure repräsentiert einen OPS-Code
  2. Gemeinsame übergeordnete Procedure optional: Kann als Gruppierung dienen
  3. Alternative: Eine der Procedures als "Haupt-Procedure" wählen (Entscheidung kann arbiträr sein)

Hinweis zur Harmonisierung: Die Entscheidung, welche Procedure als "Haupt-Procedure" gilt, kann bei komplexen Tumoroperationen schwierig und post-hoc kaum harmonisierbar sein.

Gemeinsame Aspekte bei mehrteiligen Eingriffen:

  • Zeitpunkt: Alle verknüpften Prozeduren sollten dasselbe performedDateTime haben, wenn sie in einer Sitzung durchgeführt wurden
  • Intention: Die Extension für die OP-Intention sollte bei allen verknüpften Prozeduren konsistent sein
  • Komplikationen: Können bei der betroffenen Einzelprozedur oder bei der übergeordneten Procedure dokumentiert werden
  • Residualstatus: Der lokale Residualstatus wird bei der resezierenden Prozedur dokumentiert
  • Referenzen: Alle Procedures sollten auf dieselbe Primärdiagnose (reasonReference) und ggf. Tumorboard-Empfehlung (basedOn) verweisen

Visualisierung am Beispiel Kim Musterperson

Multi-Part Surgery Example: Kim Musterperson

Extensions

Intention

Das MII-Modul Prozedur besitzt bereits eine Extension Durchführungsabsicht mit Binding auf SNOMED-CT Codes. Da die Intention der OP im oBDS jedoch durch ein oBDS-spezifisches Antwortspektrum erfasst wird, wurde die Prozedur um eine zusätzliches Element "Intention" erweitert. Vorhandene Erweiterungen des MII-Moduls Prozedur sind optional und für das Mapping von oBDS nicht direkt relevant.

Weitere Informationen: Extension Intention (Operation)

Urgency (Art des Eingriffs)

Die Extension "Urgency" erfasst die Modalität der Eingriffsdurchführung. Dieser Datenpunkt stammt ursprünglich aus dem organspezifischen Modul Kolorektales Karzinom (KRK 6 oBDS 2021), ist aber universell auf alle Procedures anwendbar und wurde daher in das allgemeine Operation-Profil integriert.

Die Extension unterscheidet zwischen:

  • E: Elektiveingriff (geplanter Eingriff)
  • N: Notfalleingriff
  • U: Unbekannt

Diese Extension ist besonders relevant für die Qualitätssicherung und statistische Auswertungen, da Notfalleingriffe oft andere Ergebnisse und Komplikationsraten aufweisen als geplante Eingriffe. Obwohl ursprünglich für kolorektale Eingriffe definiert, ist die Unterscheidung zwischen elektiven und Notfalleingriffen für alle chirurgischen Prozeduren klinisch relevant.

Verwendung:

* extension[urgency].valueCodeableConcept = $mii-cs-onko-operation-urgency#E "Elektiveingriff"

Weitere Informationen: Extension Urgency (Art des Eingriffs)

Residualstatus und weitere Beobachtungen

Der oBDS sieht bei Resektion von Tumorgewebe eine Erfassung des R-Status vor. Je nach durchgeführter Prozedur soll die Beurteilung des Residualstatus dabei lokal oder global vorgenommen werden. Diese werden im oBDS als zwei verschieden Datenpunkte erfasst. In der vorliegenden FHIR-Profilierung ist der lokale Residualstatus (wenn zutreffend) unter Procedure.outcome kodiert. Der globale Residualstatus wird über eine eigene Observation erfasst (siehe Residualstatus: Observation.)

Es gibt nebem dem Residualstatus weitere Datenpunkte, die auf eine Operation verweisen können und im oBDS gemeinsam mit dieser gemeldet werden. Dazu gehören die histologischen Untersuchungen (Lymphknoten, Grading) sowie ICD-O Morphologie, TNM und/oder ggfs. weitere Klassifikationen.

Verweise auf andere Profile

Eine im Rahmen der Krebsregister erfasste und gemeldete Operation basiert häufig auf einer Therapieempfehlung eines Tumorboards. In diesem Fall sollte eine Verknüpfung der Elemente über Procedure.basedOn(Reference(CarePlan)) hergestellt werden. Weiterhin verweist die Operation über Procedure.reasonReference auf die Primärdiagnose.

Konformität

Die vorliegende Profilierung ist kompatibel mit dem Prozedurenprofil der ISiK-Basismodule Stufe 4. https://simplifier.net/isik-basis-v4/isikprozedur

Mapping Datensatz zu FHIR

Die Zuordnung der Datensatzfelder ist im logischen Modell dokumentiert: MII LM Onkologie.

Mapping Einheitlicher onkologischer Basisdatensatz (oBDS) zu FHIR

Die oBDS-Mappings sind in der Artefaktdarstellung des Profils hinterlegt: MII PR Onkologie Operation.

Beispiele

mii-exa-onko-operation-1

Usages:

You can also check for usages in the FHIR IG Statistics

Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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
.... extension:Intention S 1..1 (Complex) Intention der OP
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Intention (required)
...... text SΣ 0..1 string Plain text representation of the concept
.... extension:Urgency S 0..1 (Complex) Art des Eingriffs
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Urgency (required)
...... text SΣ 0..1 string Plain text representation of the concept
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for basedOn SΣ 0..* Reference(CarePlan) A request for this procedure
Slice: Unordered, Open by type:$this.resolve()
.... basedOn:tumorkonferenz SΣ 0..1 Reference(MII PR Onkologie Tumorkonferenz) A request for this procedure
... partOf SΣ 0..* Reference(Observation | Procedure) Part of referenced event
... status ?!SΣ 1..1 code Status
Binding: EventStatus (required): A code specifying the state of the procedure.
... category SΣ 0..1 CodeableConcept Kategorie
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... 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 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
... 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:ops SΣ 0..1 CodingOPS OPS-Kode der Operation
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) Seitenlokalisation (OPS-Seitenzusatz R/L/B)
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 Prozedur Prozeduren [SNOMED CT] (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
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
.... 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 dateTime Durchführungsdatum
Slice: Unordered, Closed by type:$this
.... performed[x]:performedDateTime SΣ 0..1 dateTime When the procedure was performed
.... performed[x]:performedPeriod SΣ 0..1 Period Durchführungszeitraum
... reasonReference SΣ 0..* Reference(MII PR Onkologie Diagnose Primärtumor | Condition) The justification that the procedure was performed
... bodySite SΣ 0..* CodeableConcept Körperstelle
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... Slices for extension Content/Rules for all slices
..... extension:bodySite 0..1 Reference(BodyStructure) Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..1 Coding SNOMED CT Code
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version SΣ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
... outcome SΣ 0..1 CodeableConcept The result of procedure
Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required)
.... coding Σ 0..* Coding Lokaler Residualstatus
..... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus
..... code SΣ 0..1 code Symbol in syntax defined by the system
... Slices for complication S 0..* CodeableConcept Complication following the procedure
Slice: Unordered, Open by pattern:$this
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
.... complication:compl_obds S 0..* CodeableConcept Complication following the procedure
Binding: MII VS Onkologie Operation Komplikationen (required)
..... coding Σ 0..* Coding Komplikation der OP laut oBDS
...... system Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation
...... code SΣ 1..1 code Symbol in syntax defined by the system
.... complication:compl_icd10 S 0..* CodeableConcept Complication following the procedure
Binding: Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . (required)
..... coding Σ 0..* Coding Komplikation der OP Sonstige ICD-10
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... code Σ 1..1 code Symbol in syntax defined by the system
... note S 0..* Annotation Hinweis

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.extension:durchfuehrungsabsicht.​value[x] Base required MII VS Prozedur Durchführungsabsicht [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.extension:Intention.​value[x] Base required MII VS Onkologie Operation Intention 📦2027.0.0-ballot.1 This IG
Procedure.extension:Urgency.​value[x] Base required MII VS Onkologie Operation Urgency 📦2027.0.0-ballot.1 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.category.coding:sct Base preferred MII VS Prozedur OPS Kategorien [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding:ops Base required MII VS Prozedur OPS 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code.coding:ops.​extension:Seitenlokalisation.​value[x] Base required KBV_VS_SFHIR_ICD_SEITENLOKALISATION . ⏿1.00 127.0.0.1
Procedure.code.coding:sct Base required MII VS Prozedur Prozeduren [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Procedure.outcome Base required MII VS Onkologie Beurteilung des lokalen Residualstatus 📦2027.0.0-ballot.1 This IG
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Procedure.complication:compl_obds Base required MII VS Onkologie Operation Komplikationen 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_icd10 Base required Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . ⏿2026 127.0.0.1

Constraints

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()

Diese Struktur ist abgeleitet von MII_PR_Prozedur_Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* MII_PR_Prozedur_Procedure An action that is being or was performed on a patient
... extension 1..* Extension Extension
... Slices for extension Content/Rules for all slices
.... extension:Intention S 1..1 (Complex) Intention der OP
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention
..... value[x]
...... coding
....... code 1..1 code Symbol in syntax defined by the system
.... extension:Urgency S 0..1 (Complex) Art des Eingriffs
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency
..... value[x]
...... coding
....... code 1..1 code Symbol in syntax defined by the system
... Slices for basedOn S 0..* Reference(CarePlan) A request for this procedure
Slice: Unordered, Open by type:$this.resolve()
.... basedOn:tumorkonferenz S 0..1 Reference(MII PR Onkologie Tumorkonferenz) A request for this procedure
... code
.... Slices for coding Content/Rules for all slices
..... coding:ops 0..1 CodingOPS OPS-Kode der Operation
...... Slices for extension Content/Rules for all slices
....... extension:Seitenlokalisation 0..1 ExtensionSeitenlokalisation Seitenlokalisation (OPS-Seitenzusatz R/L/B)
...... version 1..1 string Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
...... code 1..1 code Der OPS-Code
... subject 1..1 Reference(Patient) Who the procedure was performed on
... performed[x] 1..1 dateTime Durchführungsdatum
... Slices for performed[x] Content/Rules for all slices
.... performed[x]:performedDateTime 0..1 dateTime When the procedure was performed
... reasonReference S 0..* Reference(MII PR Onkologie Diagnose Primärtumor | Condition) The justification that the procedure was performed
... outcome S 0..1 CodeableConcept The result of procedure
Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required)
.... coding 0..* Coding Lokaler Residualstatus
..... system S 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus
..... code S 0..1 code Symbol in syntax defined by the system
... Slices for complication S 0..* CodeableConcept Complication following the procedure
Slice: Unordered, Open by pattern:$this
.... complication:compl_obds S 0..* CodeableConcept Complication following the procedure
Binding: MII VS Onkologie Operation Komplikationen (required)
..... coding 0..* Coding Komplikation der OP laut oBDS
...... system 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation
...... code S 1..1 code Symbol in syntax defined by the system
.... complication:compl_icd10 S 0..* CodeableConcept Complication following the procedure
Binding: Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . (required)
..... coding 0..* Coding Komplikation der OP Sonstige ICD-10
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... code 1..1 code Symbol in syntax defined by the system

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.outcome Base required MII VS Onkologie Beurteilung des lokalen Residualstatus 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_obds Base required MII VS Onkologie Operation Komplikationen 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_icd10 Base required Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . ⏿2026 127.0.0.1
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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.
Additional BindingsPurpose
AllLanguages Max Binding
... 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 1..* 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
.... extension:Intention S 1..1 (Complex) Intention der OP
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Intention (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ 0..* Coding Code defined by a terminology system
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 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 SΣ 0..1 string Plain text representation of the concept
.... extension:Urgency S 0..1 (Complex) Art des Eingriffs
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Urgency (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ 0..* Coding Code defined by a terminology system
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-urgency
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 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 SΣ 0..1 string Plain text representation of the concept
... 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
... Slices for basedOn SΣ 0..* Reference(CarePlan) A request for this procedure
Slice: Unordered, Open by type:$this.resolve()
.... basedOn:tumorkonferenz SΣ 0..1 Reference(MII PR Onkologie Tumorkonferenz) A request for this procedure
... partOf SΣ 0..* Reference(Observation | Procedure) Part of referenced event
... status ?!SΣ 1..1 code Status
Binding: EventStatus (required): A code specifying the state of the procedure.
... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category SΣ 0..1 CodeableConcept Kategorie
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... 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
...... 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
... 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:ops SΣ 0..1 CodingOPS OPS-Kode der Operation
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) Seitenlokalisation (OPS-Seitenzusatz R/L/B)
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 Prozedur Prozeduren [SNOMED CT] (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
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference 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 dateTime Durchführungsdatum
Slice: Unordered, Closed by type:$this
.... 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 SΣ 0..* Reference(MII PR Onkologie Diagnose Primärtumor | Condition) 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 SΣ 0..1 CodeableConcept The result of procedure
Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Lokaler Residualstatus
..... 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 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 0..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
... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
... Slices for complication S 0..* CodeableConcept Complication following the procedure
Slice: Unordered, Open by pattern:$this
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
.... complication:compl_obds S 0..* CodeableConcept Complication following the procedure
Binding: MII VS Onkologie Operation Komplikationen (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Komplikation der OP laut oBDS
...... 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 Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation
...... 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
..... text Σ 0..1 string Plain text representation of the concept
.... complication:compl_icd10 S 0..* CodeableConcept Complication following the procedure
Binding: Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Komplikation der OP Sonstige ICD-10
...... 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 Σ 1..1 uri Identity of the terminology system
Required Pattern: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 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
... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Procedure.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Procedure.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Procedure.extension:durchfuehrungsabsicht.​value[x] Base required MII VS Prozedur Durchführungsabsicht [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.extension:Intention.​value[x] Base required MII VS Onkologie Operation Intention 📦2027.0.0-ballot.1 This IG
Procedure.extension:Urgency.​value[x] Base required MII VS Onkologie Operation Urgency 📦2027.0.0-ballot.1 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.category.coding:sct Base preferred MII VS Prozedur OPS Kategorien [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding:ops Base required MII VS Prozedur OPS 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code.coding:ops.​extension:Seitenlokalisation.​value[x] Base required KBV_VS_SFHIR_ICD_SEITENLOKALISATION . ⏿1.00 127.0.0.1
Procedure.code.coding:sct Base required MII VS Prozedur Prozeduren [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Procedure.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Procedure.performer.​function Base example Procedure Performer Role Codes 📍4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📍4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Procedure.outcome Base required MII VS Onkologie Beurteilung des lokalen Residualstatus 📦2027.0.0-ballot.1 This IG
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Procedure.complication:compl_obds Base required MII VS Onkologie Operation Komplikationen 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_icd10 Base required Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . ⏿2026 127.0.0.1
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📍4.0.1 FHIR Std.

Constraints

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()

Diese Struktur ist abgeleitet von MII_PR_Prozedur_Procedure

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 13 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Procedure.basedOn
  • The element 1 is sliced based on the value of Procedure.complication

Schlüsselelemente-Ansicht

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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
.... extension:Intention S 1..1 (Complex) Intention der OP
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Intention (required)
...... text SΣ 0..1 string Plain text representation of the concept
.... extension:Urgency S 0..1 (Complex) Art des Eingriffs
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Urgency (required)
...... text SΣ 0..1 string Plain text representation of the concept
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for basedOn SΣ 0..* Reference(CarePlan) A request for this procedure
Slice: Unordered, Open by type:$this.resolve()
.... basedOn:tumorkonferenz SΣ 0..1 Reference(MII PR Onkologie Tumorkonferenz) A request for this procedure
... partOf SΣ 0..* Reference(Observation | Procedure) Part of referenced event
... status ?!SΣ 1..1 code Status
Binding: EventStatus (required): A code specifying the state of the procedure.
... category SΣ 0..1 CodeableConcept Kategorie
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... 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 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
... 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:ops SΣ 0..1 CodingOPS OPS-Kode der Operation
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) Seitenlokalisation (OPS-Seitenzusatz R/L/B)
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 Prozedur Prozeduren [SNOMED CT] (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
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
.... 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 dateTime Durchführungsdatum
Slice: Unordered, Closed by type:$this
.... performed[x]:performedDateTime SΣ 0..1 dateTime When the procedure was performed
.... performed[x]:performedPeriod SΣ 0..1 Period Durchführungszeitraum
... reasonReference SΣ 0..* Reference(MII PR Onkologie Diagnose Primärtumor | Condition) The justification that the procedure was performed
... bodySite SΣ 0..* CodeableConcept Körperstelle
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... Slices for extension Content/Rules for all slices
..... extension:bodySite 0..1 Reference(BodyStructure) Target anatomic location or structure
URL: http://hl7.org/fhir/StructureDefinition/bodySite
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..1 Coding SNOMED CT Code
...... system SΣ 1..1 uri Identity of the terminology system
Required Pattern: http://snomed.info/sct
...... version SΣ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
... outcome SΣ 0..1 CodeableConcept The result of procedure
Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required)
.... coding Σ 0..* Coding Lokaler Residualstatus
..... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus
..... code SΣ 0..1 code Symbol in syntax defined by the system
... Slices for complication S 0..* CodeableConcept Complication following the procedure
Slice: Unordered, Open by pattern:$this
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
.... complication:compl_obds S 0..* CodeableConcept Complication following the procedure
Binding: MII VS Onkologie Operation Komplikationen (required)
..... coding Σ 0..* Coding Komplikation der OP laut oBDS
...... system Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation
...... code SΣ 1..1 code Symbol in syntax defined by the system
.... complication:compl_icd10 S 0..* CodeableConcept Complication following the procedure
Binding: Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . (required)
..... coding Σ 0..* Coding Komplikation der OP Sonstige ICD-10
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... code Σ 1..1 code Symbol in syntax defined by the system
... note S 0..* Annotation Hinweis

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.extension:durchfuehrungsabsicht.​value[x] Base required MII VS Prozedur Durchführungsabsicht [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.extension:Intention.​value[x] Base required MII VS Onkologie Operation Intention 📦2027.0.0-ballot.1 This IG
Procedure.extension:Urgency.​value[x] Base required MII VS Onkologie Operation Urgency 📦2027.0.0-ballot.1 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.category.coding:sct Base preferred MII VS Prozedur OPS Kategorien [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding:ops Base required MII VS Prozedur OPS 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code.coding:ops.​extension:Seitenlokalisation.​value[x] Base required KBV_VS_SFHIR_ICD_SEITENLOKALISATION . ⏿1.00 127.0.0.1
Procedure.code.coding:sct Base required MII VS Prozedur Prozeduren [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Procedure.outcome Base required MII VS Onkologie Beurteilung des lokalen Residualstatus 📦2027.0.0-ballot.1 This IG
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Procedure.complication:compl_obds Base required MII VS Onkologie Operation Komplikationen 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_icd10 Base required Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . ⏿2026 127.0.0.1

Constraints

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-Ansicht

Diese Struktur ist abgeleitet von MII_PR_Prozedur_Procedure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* MII_PR_Prozedur_Procedure An action that is being or was performed on a patient
... extension 1..* Extension Extension
... Slices for extension Content/Rules for all slices
.... extension:Intention S 1..1 (Complex) Intention der OP
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention
..... value[x]
...... coding
....... code 1..1 code Symbol in syntax defined by the system
.... extension:Urgency S 0..1 (Complex) Art des Eingriffs
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency
..... value[x]
...... coding
....... code 1..1 code Symbol in syntax defined by the system
... Slices for basedOn S 0..* Reference(CarePlan) A request for this procedure
Slice: Unordered, Open by type:$this.resolve()
.... basedOn:tumorkonferenz S 0..1 Reference(MII PR Onkologie Tumorkonferenz) A request for this procedure
... code
.... Slices for coding Content/Rules for all slices
..... coding:ops 0..1 CodingOPS OPS-Kode der Operation
...... Slices for extension Content/Rules for all slices
....... extension:Seitenlokalisation 0..1 ExtensionSeitenlokalisation Seitenlokalisation (OPS-Seitenzusatz R/L/B)
...... version 1..1 string Die Jahresversion des OPS Kataloges. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
...... code 1..1 code Der OPS-Code
... subject 1..1 Reference(Patient) Who the procedure was performed on
... performed[x] 1..1 dateTime Durchführungsdatum
... Slices for performed[x] Content/Rules for all slices
.... performed[x]:performedDateTime 0..1 dateTime When the procedure was performed
... reasonReference S 0..* Reference(MII PR Onkologie Diagnose Primärtumor | Condition) The justification that the procedure was performed
... outcome S 0..1 CodeableConcept The result of procedure
Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required)
.... coding 0..* Coding Lokaler Residualstatus
..... system S 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus
..... code S 0..1 code Symbol in syntax defined by the system
... Slices for complication S 0..* CodeableConcept Complication following the procedure
Slice: Unordered, Open by pattern:$this
.... complication:compl_obds S 0..* CodeableConcept Complication following the procedure
Binding: MII VS Onkologie Operation Komplikationen (required)
..... coding 0..* Coding Komplikation der OP laut oBDS
...... system 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation
...... code S 1..1 code Symbol in syntax defined by the system
.... complication:compl_icd10 S 0..* CodeableConcept Complication following the procedure
Binding: Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . (required)
..... coding 0..* Coding Komplikation der OP Sonstige ICD-10
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... code 1..1 code Symbol in syntax defined by the system

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.outcome Base required MII VS Onkologie Beurteilung des lokalen Residualstatus 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_obds Base required MII VS Onkologie Operation Komplikationen 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_icd10 Base required Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . ⏿2026 127.0.0.1

Snapshot-AnsichtView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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.
Additional BindingsPurpose
AllLanguages Max Binding
... 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 1..* 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
.... extension:Intention S 1..1 (Complex) Intention der OP
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-intention"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Intention (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ 0..* Coding Code defined by a terminology system
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-intention
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 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 SΣ 0..1 string Plain text representation of the concept
.... extension:Urgency S 0..1 (Complex) Art des Eingriffs
URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-ex-onko-operation-urgency"
..... value[x] 1..1 CodeableConcept Value of extension
Binding: MII VS Onkologie Operation Urgency (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ 0..* Coding Code defined by a terminology system
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ 1..1 uri Identity of the terminology system
Fixed Value: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-urgency
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 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 SΣ 0..1 string Plain text representation of the concept
... 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
... Slices for basedOn SΣ 0..* Reference(CarePlan) A request for this procedure
Slice: Unordered, Open by type:$this.resolve()
.... basedOn:tumorkonferenz SΣ 0..1 Reference(MII PR Onkologie Tumorkonferenz) A request for this procedure
... partOf SΣ 0..* Reference(Observation | Procedure) Part of referenced event
... status ?!SΣ 1..1 code Status
Binding: EventStatus (required): A code specifying the state of the procedure.
... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category SΣ 0..1 CodeableConcept Kategorie
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... 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
...... 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
... 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:ops SΣ 0..1 CodingOPS OPS-Kode der Operation
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) Seitenlokalisation (OPS-Seitenzusatz R/L/B)
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 Prozedur Prozeduren [SNOMED CT] (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
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference 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 dateTime Durchführungsdatum
Slice: Unordered, Closed by type:$this
.... 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 SΣ 0..* Reference(MII PR Onkologie Diagnose Primärtumor | Condition) 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 SΣ 0..1 CodeableConcept The result of procedure
Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required)
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ 0..* Coding Lokaler Residualstatus
..... 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 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-residualstatus
..... version Σ 0..1 string Version of the system - if relevant
..... code SΣ 0..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
... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
... Slices for complication S 0..* CodeableConcept Complication following the procedure
Slice: Unordered, Open by pattern:$this
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
.... complication:compl_obds S 0..* CodeableConcept Complication following the procedure
Binding: MII VS Onkologie Operation Komplikationen (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Komplikation der OP laut oBDS
...... 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 Σ 0..1 uri Identity of the terminology system
Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation
...... 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
..... text Σ 0..1 string Plain text representation of the concept
.... complication:compl_icd10 S 0..* CodeableConcept Complication following the procedure
Binding: Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Komplikation der OP Sonstige ICD-10
...... 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 Σ 1..1 uri Identity of the terminology system
Required Pattern: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 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
... 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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Procedure.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Procedure.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Procedure.extension:durchfuehrungsabsicht.​value[x] Base required MII VS Prozedur Durchführungsabsicht [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.extension:Intention.​value[x] Base required MII VS Onkologie Operation Intention 📦2027.0.0-ballot.1 This IG
Procedure.extension:Urgency.​value[x] Base required MII VS Onkologie Operation Urgency 📦2027.0.0-ballot.1 This IG
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.statusReason Base example Procedure Not Performed Reason (SNOMED-CT) 📍4.0.1 FHIR Std.
Procedure.category Base example Procedure Category Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.category.coding:sct Base preferred MII VS Prozedur OPS Kategorien [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding:ops Base required MII VS Prozedur OPS 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.code.coding:ops.​extension:Seitenlokalisation.​value[x] Base required KBV_VS_SFHIR_ICD_SEITENLOKALISATION . ⏿1.00 127.0.0.1
Procedure.code.coding:sct Base required MII VS Prozedur Prozeduren [SNOMED CT] 📦2027.0.0-ballot MII Implementation Guide Core Dataset Base v2027.0
Procedure.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Procedure.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Procedure.performer.​function Base example Procedure Performer Role Codes 📍4.0.1 FHIR Std.
Procedure.reasonCode Base example Procedure Reason Codes 📍4.0.1 FHIR Std.
Procedure.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Procedure.outcome Base required MII VS Onkologie Beurteilung des lokalen Residualstatus 📦2027.0.0-ballot.1 This IG
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Procedure.complication:compl_obds Base required MII VS Onkologie Operation Komplikationen 📦2027.0.0-ballot.1 This IG
Procedure.complication:compl_icd10 Base required Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme . ⏿2026 127.0.0.1
Procedure.followUp Base example Procedure Follow up Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.focalDevice.​action Base preferred Procedure Device Action Codes 📍4.0.1 FHIR Std.
Procedure.usedCode Base example FHIR Device Types 📍4.0.1 FHIR Std.

Constraints

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()

Diese Struktur ist abgeleitet von MII_PR_Prozedur_Procedure

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 13 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Procedure.basedOn
  • The element 1 is sliced based on the value of Procedure.complication

 

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