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

Resource Profile: MII PR Onkologie Präoperative Markierung Mamma

Official URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-mamma-praeoperative-markierung Version: 2027.0.0-ballot.1
Active as of 2026-09-15 Computable Name: MII_PR_Onko_Mamma_Praeoperative_Markierung

Das vorliegende Profil beschreibt eine präoperativ durchgeführte Markierung von Tumorgewebe in der Brust. Dabei können verschiedene Markierungsmodalitäten gewählt werden, wie z.B. Drahtmarkierungen, Seed-Markierungen oder andere Lokalisationstechniken.

Content

The Mamma Preoperative Marking Profile documents radiologically performed markings of tumor tissue in the breast prior to surgical procedures. This profile is based on the FHIR Procedure resource and captures various marking modalities used for the precise localization of tumor tissue.

Preoperative marking is an important part of breast-conserving therapy and enables surgeons to precisely localize and completely remove non-palpable lesions.

The profile is closely linked to other oncology resources:

  • refers via Procedure.partOf to the parent operation (MII_PR_Onko_Operation)
  • refers via Procedure.subject to the patient (Patient resource)
  • can be linked via Procedure.encounter to a specific treatment case

oBDS context

The profile implements breast-specific marking procedures as an extension of the general oBDS operation dataset. Preoperative marking is particularly relevant for:

Clinical applications:

  • Breast-conserving therapy: precise localization of non-palpable tumors
  • Multifocal tumors: marking of multiple tumor foci
  • Re-excision: marking for R1 resections
  • Quality assurance: documentation of marking quality

Marking modalities (currently in the ValueSet):

  • Wire marking with ultrasound guidance: SNOMED CT 433222002
  • Marker insertion with X-ray guidance: SNOMED CT 836381000000102
  • Wire marking with MRI guidance: SNOMED CT 911831000000104

Further clinically relevant modalities (not yet in the ValueSet):

  • Radioactive seed marking: radioactive seeds for localization
  • Magnetic seed marking: modern wireless procedures (e.g. Magseed®)
  • Clip marking: metal clips for orientation

Note: The current ValueSet focuses on imaging-guided wire and marker procedures. Modern seed-based procedures could be added in future versions.

Terminology binding

The profile uses extensible binding for marking modalities directly on Procedure.code:

ValueSet: MII VS Onko Mamma Präoperative Markierung Modalität

The codes it contains are listed in the artefact view: MII VS Onkologie Mamma Präoperative Markierung Modalität.

The codes it contains are listed in the artefact view: MII VS Onkologie Mamma Präoperative Markierung Modalität.

Mapping dataset to FHIR

The mapping of the dataset fields is documented in the logical model: MII LM Onkologie Organspezifische Zusatzmodule.

Mapping Einheitlicher onkologischer Basisdatensatz (oBDS) to FHIR

The oBDS mappings are recorded in the artefact view of this profile: MII PR Onkologie Präoperative Markierung Mamma.

Examples

mii-exa-onko-mamma-praeoperative-markierung-1

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and their representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta Σ 0..1 Meta Metadata about the resource
.... 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.
... code SΣ 1..1 CodeableConcept Präoperative Tumormarkierung
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
.... coding SΣ 0..* Coding Code defined by a terminology system
Binding: MII VS Onkologie Mamma Präoperative Markierung Modalität (extensible)
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for performed[x] Σ 0..1 When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
.... performed[x]:performedDateTime Σ 0..1 dateTime When the procedure was performed

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding Base extensible MII VS Onkologie Mamma Präoperative Markierung Modalität 📦2027.0.0-ballot.1 This IG

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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... partOf S 0..* Reference(MII PR Onkologie Operation) Part of referenced event
... status S 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
.... coding S 0..* Coding Code defined by a terminology system
Binding: MII VS Onkologie Mamma Präoperative Markierung Modalität (extensible)
... subject S 1..1 Reference(Patient) Who the procedure was performed on
... encounter S 0..1 Reference(Encounter) Encounter created as part of
... Slices for performed[x] 0..1 dateTime, Period, string, Age, Range When the procedure was performed
Slice: Unordered, Open by type:$this
.... performed[x]:performedDateTime 0..1 dateTime When the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.code.coding Base extensible MII VS Onkologie Mamma Präoperative Markierung Modalität 📦2027.0.0-ballot.1 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... 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 Σ 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
... partOf SΣ 0..* Reference(MII PR Onkologie Operation) Part of referenced event
... status ?!SΣ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.
... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category Σ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
... code SΣ 1..1 CodeableConcept Präoperative Tumormarkierung
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 0..* Coding Code defined by a terminology system
Binding: MII VS Onkologie Mamma Präoperative Markierung Modalität (extensible)
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for performed[x] Σ 0..1 When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
.... performed[x]:performedDateTime Σ 0..1 dateTime When the procedure was performed
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
... performer Σ 0..* BackboneElement The people who performed the procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location Σ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... outcome Σ 0..1 CodeableConcept The result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
... followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
... note 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
.... manipulated 1..1 Reference(Device) Device that was changed
... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
... usedCode 0..* CodeableConcept Coded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.

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.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.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding Base extensible MII VS Onkologie Mamma Präoperative Markierung Modalität 📦2027.0.0-ballot.1 This IG
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 example Procedure Outcome Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
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()

Summary

Mandatory: 1 element
Must-Support: 7 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Procedure.performed[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta Σ 0..1 Meta Metadata about the resource
.... 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.
... code SΣ 1..1 CodeableConcept Präoperative Tumormarkierung
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
.... coding SΣ 0..* Coding Code defined by a terminology system
Binding: MII VS Onkologie Mamma Präoperative Markierung Modalität (extensible)
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for performed[x] Σ 0..1 When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
.... performed[x]:performedDateTime Σ 0..1 dateTime When the procedure was performed

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Procedure.status Base required EventStatus 📍4.0.1 FHIR Std.
Procedure.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding Base extensible MII VS Onkologie Mamma Präoperative Markierung Modalität 📦2027.0.0-ballot.1 This IG

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()

Differential View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... meta
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... partOf S 0..* Reference(MII PR Onkologie Operation) Part of referenced event
... status S 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
.... coding S 0..* Coding Code defined by a terminology system
Binding: MII VS Onkologie Mamma Präoperative Markierung Modalität (extensible)
... subject S 1..1 Reference(Patient) Who the procedure was performed on
... encounter S 0..1 Reference(Encounter) Encounter created as part of
... Slices for performed[x] 0..1 dateTime, Period, string, Age, Range When the procedure was performed
Slice: Unordered, Open by type:$this
.... performed[x]:performedDateTime 0..1 dateTime When the procedure was performed

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Procedure.code.coding Base extensible MII VS Onkologie Mamma Präoperative Markierung Modalität 📦2027.0.0-ballot.1 This IG

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Procedure 0..* Procedure An action that is being or was performed on a patient
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... 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 Σ 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Identifiers for this procedure
... instantiatesCanonical Σ 0..* canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) Instantiates FHIR protocol or definition
... instantiatesUri Σ 0..* uri Instantiates external protocol or definition
... basedOn Σ 0..* Reference(CarePlan | ServiceRequest) A request for this procedure
... partOf SΣ 0..* Reference(MII PR Onkologie Operation) Part of referenced event
... status ?!SΣ 1..1 code preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.
... statusReason Σ 0..1 CodeableConcept Reason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.
... category Σ 0..1 CodeableConcept Classification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.
... code SΣ 1..1 CodeableConcept Präoperative Tumormarkierung
Binding: ProcedureCodes(SNOMEDCT) (example): A code to identify a specific procedure .
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ 0..* Coding Code defined by a terminology system
Binding: MII VS Onkologie Mamma Präoperative Markierung Modalität (extensible)
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who the procedure was performed on
... encounter SΣ 0..1 Reference(Encounter) Encounter created as part of
... Slices for performed[x] Σ 0..1 When the procedure was performed
Slice: Unordered, Open by type:$this
.... performedDateTime dateTime
.... performedPeriod Period
.... performedString string
.... performedAge Age
.... performedRange Range
.... performed[x]:performedDateTime Σ 0..1 dateTime When the procedure was performed
... recorder Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Who recorded the procedure
... asserter Σ 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) Person who asserts this procedure
... performer Σ 0..* BackboneElement The people who performed the procedure
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... function Σ 0..1 CodeableConcept Type of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.
.... actor Σ 1..1 Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) The reference to the practitioner
.... onBehalfOf 0..1 Reference(Organization) Organization the device or practitioner was acting for
... location Σ 0..1 Reference(Location) Where the procedure happened
... reasonCode Σ 0..* CodeableConcept Coded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.
... reasonReference Σ 0..* Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) The justification that the procedure was performed
... bodySite Σ 0..* CodeableConcept Target body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
... outcome Σ 0..1 CodeableConcept The result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.
... report 0..* Reference(DiagnosticReport | DocumentReference | Composition) Any report resulting from the procedure
... complication 0..* CodeableConcept Complication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.
... complicationDetail 0..* Reference(Condition) A condition that is a result of the procedure
... followUp 0..* CodeableConcept Instructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.
... note 0..* Annotation Additional information about the procedure
... focalDevice 0..* BackboneElement Manipulated, implanted, or removed device
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... action 0..1 CodeableConcept Kind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.
.... manipulated 1..1 Reference(Device) Device that was changed
... usedReference 0..* Reference(Device | Medication | Substance) Items used during procedure
... usedCode 0..* CodeableConcept Coded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.

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.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.code Base example Procedure Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.code.coding Base extensible MII VS Onkologie Mamma Präoperative Markierung Modalität 📦2027.0.0-ballot.1 This IG
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 example Procedure Outcome Codes (SNOMED CT) 📍4.0.1 FHIR Std.
Procedure.complication Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
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()

Summary

Mandatory: 1 element
Must-Support: 7 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Procedure.performed[x]

 

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