Kerndatensatz Senologie - Local Development build (v0.9.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Resource Profile: BIH LM Senologie Brustwand-Operation
| Official URL: https://www.senologie.org/fhir/StructureDefinition/senologie-operation | Version: 0.9.0 | |||
| Draft as of 2026-05-04 | Computable Name: Senologie_Operation | |||
Operationen im Rahmen der BIH-Spezifikation des Moduls Senologie. Erbt Intention, PräoperativeMarkierung und IntraoperativesImaging von MII Onko Mamma Operation.
Usages:
- Examples for this Profile: Procedure/Example-Operation-BET, Procedure/Example-Operation-SLNB, Procedure/Fall1-Operation-BET, Procedure/Fall1-Operation-SLNB... Show 23 more
You can also check for usages in the FHIR IG Statistics
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Procedure |
C | 0..* | MII_PR_Onko_Mamma_Operation | An action that is being or was performed on a patient Constraints: proc-mii-1 |
  id |
SΣ | 0..1 | id | Logical id of this artifact |
  meta |
SΣ | 0..1 | Meta | Metadata about the resource |
 source |
SΣ | 0..1 | uri | Identifies where the resource comes from |
 profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 Slices for extension |
S | 1..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
  extension:Dokumentationsdatum |
S | 0..1 | dateTime | Recorded date URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum |
| extension:durchfuehrungsabsicht |
S | 0..1 | Coding | Intention URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (required) |
 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 | Additional content defined by implementations 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 | Additional content defined by implementations 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_Onko_Operation_Urgency (required) | |
| text |
SΣ | 0..1 | string | Plain text representation of the concept |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Slice: Unordered, Open by value:url |
 basedOn |
SΣC | 0..* | Reference(CarePlan) | A request for this procedure Constraints: ref-1 |
| partOf |
SΣC | 0..* | Reference(MII PR Onkologie Operation) | Part of referenced event Constraints: ref-1 |
| status |
?!SΣ | 1..1 | code | Status Binding: EventStatus (required): A code specifying the state of the procedure. |
| category |
SΣ | 0..1 | CodeableConcept | Art der Operation Binding: BIH LM Senologie Operation (required) |
  Slices for coding |
Σ | 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 code Binding: MII_VS_Onko_Mamma_Operation_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 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) |
| 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_Onko_Mamma_Operation_SCT (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| version |
0..1 | string | Version of the system - if relevant | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| system |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| subject |
SΣC | 1..1 | Reference(Patient) | Who the procedure was performed on Constraints: ref-1 |
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter Constraints: ref-1 |
| Slices for performed[x] |
SΣ | 1..1 | dateTime | Performed date Slice: Unordered, Open by type:$this |
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed |
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Performed period |
| Slices for performer |
SΣ | 0..* | BackboneElement | The people who performed the procedure Slice: Unordered, Open by pattern:function |
 performer:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| actor |
ΣC | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner Constraints: ref-1 |
| performer:erstoperateur |
SΣ | 0..1 | BackboneElement | The people who performed the procedure |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function |
Σ | 1..1 | CodeableConcept | Erstoperateur (G08) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 304292004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgeon (occupation) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 |
| performer:zweitoperateur |
SΣ | 0..1 | BackboneElement | The people who performed the procedure |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function |
Σ | 1..1 | CodeableConcept | Zweitoperateur (G09) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 309388001 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgical assistant (occupation) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 |
| reasonReference |
SΣC | 0..* | Reference(MII PR Onkologie Diagnose Primärtumor) | Bezogene Diagnose Constraints: ref-1 |
| bodySite |
SΣ | 0..* | CodeableConcept | Body site Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| 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 | Outcome der Operation, v.a. bei Revision Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required): An outcome of a procedure - whether it was resolved or otherwise. |
| 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 | Komplikation (oBDS / ICD-10) 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): Codes describing complications that resulted from a procedure. |
| 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: ICD10GM ValueSet (required): Codes describing complications that resulted from a procedure. |
| Slices for followUp |
S | 0..* | CodeableConcept | Instructions for follow up Slice: Unordered, Open by pattern:$this Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. |
| followUp:drainage |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 122462000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Drainage procedure | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:verband |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182531007 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dressing of wound | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:antibiotika |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 281789004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Antibiotic therapy (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:mobilisation |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 183040004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Mobilization (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:laborkontrolle |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 15220000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory test (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| note |
S | 0..* | Annotation | Note |
| Slices for usedCode |
S | 0..* | CodeableConcept | Verwendete Codes Slice: Unordered, Open by pattern:$this Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. |
| usedCode:IntraoperativesImaging |
S | 0..* | CodeableConcept | Intraoperatives Präparateröntgen/Sonografie Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. |
| usedCode:PraeoperativeMarkierung |
S | 0..* | CodeableConcept | Präoperative Markierung Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. |
| Documentation for this format | ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.extension:Intention.value[x] | Base | required | MII VS Onkologie Operation Intention | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.extension:Urgency.value[x] | Base | required | MII_VS_Onko_Operation_Urgency | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.category | Base | required | BIH LM Senologie Operation | 📦0.9.0 | This IG |
| Procedure.category.coding:sct | Base | preferred | MII VS Prozedur OPS Kategorien [SNOMED CT] | 📦2026.0.0 | MII IG Core Dataset Base v2026.0 |
| Procedure.code | Base | example | Procedure Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code.coding:ops | Base | required | MII_VS_Onko_Mamma_Operation_OPS | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.code.coding:sct | Base | required | MII_VS_Onko_Mamma_Operation_SCT | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.performer:erstoperateur.function | Base | example | Procedure Performer Role Codes | 📦4.0.1 | FHIR Std. |
| Procedure.performer:zweitoperateur.function | Base | example | Procedure Performer Role 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 | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📦4.0.1 | FHIR Std. |
| Procedure.complication:compl_obds | Base | required | MII VS Onkologie Operation Komplikationen | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication:compl_icd10 | Base | required | ICD10GM ValueSet | 📦1.5.4 | de.basisprofil.r4 v1.5 |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:drainage | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:verband | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:antibiotika | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:mobilisation | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:laborkontrolle | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:IntraoperativesImaging | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:PraeoperativeMarkierung | 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()
|
| ref-1 | error | Procedure.basedOn, Procedure.partOf, Procedure.subject, Procedure.encounter, Procedure.performer.actor, Procedure.performer:erstoperateur.actor, Procedure.performer:zweitoperateur.actor, Procedure.reasonReference | SHALL have a contained resource if a local reference is provided |
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
|
| 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()
|
This structure is derived from MII_PR_Onko_Mamma_Operation
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
0..* | MII_PR_Onko_Mamma_Operation | An action that is being or was performed on a patient | |
| category |
0..1 | CodeableConcept | Art der Operation Binding: BIH LM Senologie Operation (required) | |
| Slices for performer |
S | 0..* | BackboneElement | The people who performed the procedure Slice: Unordered, Open by pattern:function |
| performer:erstoperateur |
S | 0..1 | BackboneElement | The people who performed the procedure |
| function |
1..1 | CodeableConcept | Erstoperateur (G08) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 304292004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgeon (occupation) | |
| actor |
S | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner |
| performer:zweitoperateur |
S | 0..1 | BackboneElement | The people who performed the procedure |
| function |
1..1 | CodeableConcept | Zweitoperateur (G09) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 309388001 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgical assistant (occupation) | |
| actor |
S | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner |
| reasonReference |
0..* | Reference(MII PR Onkologie Diagnose Primärtumor) | Bezogene Diagnose | |
| outcome |
0..1 | CodeableConcept | Outcome der Operation, v.a. bei Revision | |
| complication |
0..* | CodeableConcept | Komplikation (oBDS / ICD-10) | |
| Slices for followUp |
S | 0..* | CodeableConcept | Instructions for follow up Slice: Unordered, Open by pattern:$this |
| followUp:drainage |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 122462000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Drainage procedure | |
| followUp:verband |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182531007 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dressing of wound | |
| followUp:antibiotika |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 281789004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Antibiotic therapy (procedure) | |
| followUp:mobilisation |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 183040004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Mobilization (procedure) | |
| followUp:laborkontrolle |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 15220000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory test (procedure) | |
| usedCode |
0..* | CodeableConcept | Verwendete Codes | |
| Documentation for this format | ||||
Terminology Bindings (Differential)
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.category | Base | required | BIH LM Senologie Operation | 📦0.9.0 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | MII_PR_Onko_Mamma_Operation | An action that is being or was performed on a patient Constraints: proc-mii-1 | ||||
| id |
SΣ | 0..1 | id | Logical id of this artifact | ||||
| meta |
SΣ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
SΣ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
S | 1..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||
| extension:Dokumentationsdatum |
S | 0..1 | dateTime | Recorded date URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum | ||||
| extension:durchfuehrungsabsicht |
S | 0..1 | Coding | Intention URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (required) | ||||
| 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 | Additional content defined by implementations 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 | Additional content defined by implementations 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_Onko_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 Slice: Unordered, Open by value:url | ||||
| 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 |
SΣC | 0..* | Reference(CarePlan) | A request for this procedure Constraints: ref-1 | ||||
| partOf |
SΣC | 0..* | Reference(MII PR Onkologie Operation) | Part of referenced event Constraints: ref-1 | ||||
| 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 | Art der Operation Binding: BIH LM Senologie Operation (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 | |||||
| Slices for coding |
Σ | 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 code Binding: MII_VS_Onko_Mamma_Operation_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 | |||||
| extension:Seitenlokalisation |
S | 0..1 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) | ||||
| 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_Onko_Mamma_Operation_SCT (required) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
SΣC | 1..1 | Reference(Patient) | Who the procedure was performed on Constraints: ref-1 | ||||
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter Constraints: ref-1 | ||||
| Slices for performed[x] |
SΣ | 1..1 | dateTime | Performed date Slice: Unordered, Open by type:$this | ||||
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed | ||||
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Performed period | ||||
| recorder |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure Constraints: ref-1 | ||||
| asserter |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure Constraints: ref-1 | ||||
| Slices for performer |
SΣ | 0..* | BackboneElement | The people who performed the procedure Slice: Unordered, Open by pattern:function | ||||
| performer:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| 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 |
ΣC | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| performer:erstoperateur |
SΣ | 0..1 | 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 Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 1..1 | CodeableConcept | Erstoperateur (G08) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 304292004 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgeon (occupation) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| performer:zweitoperateur |
SΣ | 0..1 | 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 Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 1..1 | CodeableConcept | Zweitoperateur (G09) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 309388001 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgical assistant (occupation) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| location |
ΣC | 0..1 | Reference(Location) | Where the procedure happened Constraints: ref-1 | ||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
SΣC | 0..* | Reference(MII PR Onkologie Diagnose Primärtumor) | Bezogene Diagnose Constraints: ref-1 | ||||
| bodySite |
SΣ | 0..* | CodeableConcept | Body site Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| 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: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 | Outcome der Operation, v.a. bei Revision Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
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 |
C | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure Constraints: ref-1 | ||||
| Slices for complication |
S | 0..* | CodeableConcept | Komplikation (oBDS / ICD-10) 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): Codes describing complications that resulted from a 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 |
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: ICD10GM ValueSet (required): Codes describing complications that resulted from a 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 |
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 |
C | 0..* | Reference(Condition) | A condition that is a result of the procedure Constraints: ref-1 | ||||
| Slices for followUp |
S | 0..* | CodeableConcept | Instructions for follow up Slice: Unordered, Open by pattern:$this Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | ||||
| followUp:drainage |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 122462000 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Drainage procedure | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:verband |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182531007 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Dressing of wound | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:antibiotika |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 281789004 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Antibiotic therapy (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:mobilisation |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 183040004 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Mobilization (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:laborkontrolle |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 15220000 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory test (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| note |
S | 0..* | Annotation | Note | ||||
| 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 Slice: Unordered, Open by value:url | |||||
| 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 |
C | 1..1 | Reference(Device) | Device that was changed Constraints: ref-1 | ||||
| usedReference |
C | 0..* | Reference(Device | Medication | Substance) | Items used during procedure Constraints: ref-1 | ||||
| Slices for usedCode |
S | 0..* | CodeableConcept | Verwendete Codes Slice: Unordered, Open by pattern:$this Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | ||||
| usedCode:IntraoperativesImaging |
S | 0..* | CodeableConcept | Intraoperatives Präparateröntgen/Sonografie Binding: FHIRDeviceTypes (example): Codes describing items used during a 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 |
Σ | 0..* | Coding | Code defined by a terminology system Binding: MII_VS_Onko_Mamma_Intraoperatives_Imaging_Praeparat (extensible) | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| usedCode:PraeoperativeMarkierung |
S | 0..* | CodeableConcept | Präoperative Markierung Binding: FHIRDeviceTypes (example): Codes describing items used during a 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 |
Σ | 0..* | Coding | Code defined by a terminology system Binding: MII_VS_Onko_Mamma_Praeoperative_Markierung_Modalitaet (extensible) | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| 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:Intention.value[x] | Base | required | MII VS Onkologie Operation Intention | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.extension:Urgency.value[x] | Base | required | MII_VS_Onko_Operation_Urgency | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| 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 | required | BIH LM Senologie Operation | 📦0.9.0 | This IG |
| Procedure.category.coding:sct | Base | preferred | MII VS Prozedur OPS Kategorien [SNOMED CT] | 📦2026.0.0 | MII IG Core Dataset Base v2026.0 |
| Procedure.code | Base | example | Procedure Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code.coding:ops | Base | required | MII_VS_Onko_Mamma_Operation_OPS | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.code.coding:sct | Base | required | MII_VS_Onko_Mamma_Operation_SCT | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.performer.function | Base | example | Procedure Performer Role Codes | 📦4.0.1 | FHIR Std. |
| Procedure.performer:erstoperateur.function | Base | example | Procedure Performer Role Codes | 📦4.0.1 | FHIR Std. |
| Procedure.performer:zweitoperateur.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 | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📦4.0.1 | FHIR Std. |
| Procedure.complication:compl_obds | Base | required | MII VS Onkologie Operation Komplikationen | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication:compl_icd10 | Base | required | ICD10GM ValueSet | 📦1.5.4 | de.basisprofil.r4 v1.5 |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:drainage | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:verband | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:antibiotika | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:mobilisation | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:laborkontrolle | 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. |
| Procedure.usedCode:IntraoperativesImaging | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:IntraoperativesImaging.coding | Base | extensible | MII_VS_Onko_Mamma_Intraoperatives_Imaging_Praeparat | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.usedCode:PraeoperativeMarkierung | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:PraeoperativeMarkierung.coding | Base | extensible | MII_VS_Onko_Mamma_Praeoperative_Markierung_Modalitaet | 📦2026.0.3 | MII IG Onkologie v2026.0 |
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()
|
| ref-1 | error | Procedure.basedOn, Procedure.partOf, Procedure.subject, Procedure.encounter, Procedure.recorder, Procedure.asserter, Procedure.performer.actor, Procedure.performer.onBehalfOf, Procedure.performer:erstoperateur.actor, Procedure.performer:erstoperateur.onBehalfOf, Procedure.performer:zweitoperateur.actor, Procedure.performer:zweitoperateur.onBehalfOf, Procedure.location, Procedure.reasonReference, Procedure.report, Procedure.complicationDetail, Procedure.focalDevice.manipulated, Procedure.usedReference | SHALL have a contained resource if a local reference is provided |
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
|
| 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()
|
This structure is derived from MII_PR_Onko_Mamma_Operation
Summary
Mandatory: 0 element(2 nested mandatory elements)
Must-Support: 11 elements
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of Procedure.performer
- The element 1 is sliced based on the value of Procedure.followUp
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
C | 0..* | MII_PR_Onko_Mamma_Operation | An action that is being or was performed on a patient Constraints: proc-mii-1 |
| id |
SΣ | 0..1 | id | Logical id of this artifact |
| meta |
SΣ | 0..1 | Meta | Metadata about the resource |
| source |
SΣ | 0..1 | uri | Identifies where the resource comes from |
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
S | 1..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| extension:Dokumentationsdatum |
S | 0..1 | dateTime | Recorded date URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum |
| extension:durchfuehrungsabsicht |
S | 0..1 | Coding | Intention URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (required) |
| 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 | Additional content defined by implementations 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 | Additional content defined by implementations 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_Onko_Operation_Urgency (required) | |
| text |
SΣ | 0..1 | string | Plain text representation of the concept |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Slice: Unordered, Open by value:url |
| basedOn |
SΣC | 0..* | Reference(CarePlan) | A request for this procedure Constraints: ref-1 |
| partOf |
SΣC | 0..* | Reference(MII PR Onkologie Operation) | Part of referenced event Constraints: ref-1 |
| status |
?!SΣ | 1..1 | code | Status Binding: EventStatus (required): A code specifying the state of the procedure. |
| category |
SΣ | 0..1 | CodeableConcept | Art der Operation Binding: BIH LM Senologie Operation (required) |
| Slices for coding |
Σ | 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 code Binding: MII_VS_Onko_Mamma_Operation_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 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) |
| 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_Onko_Mamma_Operation_SCT (required) Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| version |
0..1 | string | Version of the system - if relevant | |
| display |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| system |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| subject |
SΣC | 1..1 | Reference(Patient) | Who the procedure was performed on Constraints: ref-1 |
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter Constraints: ref-1 |
| Slices for performed[x] |
SΣ | 1..1 | dateTime | Performed date Slice: Unordered, Open by type:$this |
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed |
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Performed period |
| Slices for performer |
SΣ | 0..* | BackboneElement | The people who performed the procedure Slice: Unordered, Open by pattern:function |
| performer:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| actor |
ΣC | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner Constraints: ref-1 |
| performer:erstoperateur |
SΣ | 0..1 | BackboneElement | The people who performed the procedure |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function |
Σ | 1..1 | CodeableConcept | Erstoperateur (G08) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 304292004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgeon (occupation) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 |
| performer:zweitoperateur |
SΣ | 0..1 | BackboneElement | The people who performed the procedure |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| function |
Σ | 1..1 | CodeableConcept | Zweitoperateur (G09) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 309388001 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgical assistant (occupation) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 |
| reasonReference |
SΣC | 0..* | Reference(MII PR Onkologie Diagnose Primärtumor) | Bezogene Diagnose Constraints: ref-1 |
| bodySite |
SΣ | 0..* | CodeableConcept | Body site Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. |
| 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 | Outcome der Operation, v.a. bei Revision Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required): An outcome of a procedure - whether it was resolved or otherwise. |
| 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 | Komplikation (oBDS / ICD-10) Slice: Unordered, Open by pattern:$this Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure. |
| complication:compl_obds |
S | 0..* | CodeableConcept | Complication following the procedure Binding: MII VS Onkologie Operation Komplikationen (required): Codes describing complications that resulted from a procedure. |
| coding |
Σ | 0..* | Coding | Komplikation der OP laut oBDS |
| system |
Σ | 0..1 | uri | Identity of the terminology system Required Pattern: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/CodeSystem/mii-cs-onko-operation-komplikation |
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system |
| complication:compl_icd10 |
S | 0..* | CodeableConcept | Complication following the procedure Binding: ICD10GM ValueSet (required): Codes describing complications that resulted from a procedure. |
| Slices for followUp |
S | 0..* | CodeableConcept | Instructions for follow up Slice: Unordered, Open by pattern:$this Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. |
| followUp:drainage |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 122462000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Drainage procedure | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:verband |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182531007 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dressing of wound | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:antibiotika |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 281789004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Antibiotic therapy (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:mobilisation |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 183040004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Mobilization (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| followUp:laborkontrolle |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. Required Pattern: At least the following | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| text |
0..1 | string | Plain text representation of the concept | |
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 15220000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory test (procedure) | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| note |
S | 0..* | Annotation | Note |
| Slices for usedCode |
S | 0..* | CodeableConcept | Verwendete Codes Slice: Unordered, Open by pattern:$this Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. |
| usedCode:IntraoperativesImaging |
S | 0..* | CodeableConcept | Intraoperatives Präparateröntgen/Sonografie Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. |
| usedCode:PraeoperativeMarkierung |
S | 0..* | CodeableConcept | Präoperative Markierung Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. |
| Documentation for this format | ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.extension:Intention.value[x] | Base | required | MII VS Onkologie Operation Intention | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.extension:Urgency.value[x] | Base | required | MII_VS_Onko_Operation_Urgency | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.status | Base | required | EventStatus | 📍4.0.1 | FHIR Std. |
| Procedure.category | Base | required | BIH LM Senologie Operation | 📦0.9.0 | This IG |
| Procedure.category.coding:sct | Base | preferred | MII VS Prozedur OPS Kategorien [SNOMED CT] | 📦2026.0.0 | MII IG Core Dataset Base v2026.0 |
| Procedure.code | Base | example | Procedure Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code.coding:ops | Base | required | MII_VS_Onko_Mamma_Operation_OPS | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.code.coding:sct | Base | required | MII_VS_Onko_Mamma_Operation_SCT | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.performer:erstoperateur.function | Base | example | Procedure Performer Role Codes | 📦4.0.1 | FHIR Std. |
| Procedure.performer:zweitoperateur.function | Base | example | Procedure Performer Role 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 | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📦4.0.1 | FHIR Std. |
| Procedure.complication:compl_obds | Base | required | MII VS Onkologie Operation Komplikationen | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication:compl_icd10 | Base | required | ICD10GM ValueSet | 📦1.5.4 | de.basisprofil.r4 v1.5 |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:drainage | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:verband | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:antibiotika | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:mobilisation | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:laborkontrolle | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:IntraoperativesImaging | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:PraeoperativeMarkierung | 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()
|
| ref-1 | error | Procedure.basedOn, Procedure.partOf, Procedure.subject, Procedure.encounter, Procedure.performer.actor, Procedure.performer:erstoperateur.actor, Procedure.performer:zweitoperateur.actor, Procedure.reasonReference | SHALL have a contained resource if a local reference is provided |
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
|
| sct-ops-1 | error | Procedure.code | Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden. |
coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()
|
Differential View
This structure is derived from MII_PR_Onko_Mamma_Operation
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Procedure |
0..* | MII_PR_Onko_Mamma_Operation | An action that is being or was performed on a patient | |
| category |
0..1 | CodeableConcept | Art der Operation Binding: BIH LM Senologie Operation (required) | |
| Slices for performer |
S | 0..* | BackboneElement | The people who performed the procedure Slice: Unordered, Open by pattern:function |
| performer:erstoperateur |
S | 0..1 | BackboneElement | The people who performed the procedure |
| function |
1..1 | CodeableConcept | Erstoperateur (G08) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 304292004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgeon (occupation) | |
| actor |
S | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner |
| performer:zweitoperateur |
S | 0..1 | BackboneElement | The people who performed the procedure |
| function |
1..1 | CodeableConcept | Zweitoperateur (G09) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 309388001 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgical assistant (occupation) | |
| actor |
S | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner |
| reasonReference |
0..* | Reference(MII PR Onkologie Diagnose Primärtumor) | Bezogene Diagnose | |
| outcome |
0..1 | CodeableConcept | Outcome der Operation, v.a. bei Revision | |
| complication |
0..* | CodeableConcept | Komplikation (oBDS / ICD-10) | |
| Slices for followUp |
S | 0..* | CodeableConcept | Instructions for follow up Slice: Unordered, Open by pattern:$this |
| followUp:drainage |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 122462000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Drainage procedure | |
| followUp:verband |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182531007 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dressing of wound | |
| followUp:antibiotika |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 281789004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Antibiotic therapy (procedure) | |
| followUp:mobilisation |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 183040004 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Mobilization (procedure) | |
| followUp:laborkontrolle |
0..* | CodeableConcept | Instructions for follow up Required Pattern: At least the following | |
| coding |
S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 15220000 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory test (procedure) | |
| usedCode |
0..* | CodeableConcept | Verwendete Codes | |
| Documentation for this format | ||||
Terminology Bindings (Differential)
| Path | Status | Usage | ValueSet | Version | Source |
| Procedure.category | Base | required | BIH LM Senologie Operation | 📦0.9.0 | This IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure |
C | 0..* | MII_PR_Onko_Mamma_Operation | An action that is being or was performed on a patient Constraints: proc-mii-1 | ||||
| id |
SΣ | 0..1 | id | Logical id of this artifact | ||||
| meta |
SΣ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
SΣ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
S | 1..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | ||||
| extension:Dokumentationsdatum |
S | 0..1 | dateTime | Recorded date URL: http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum | ||||
| extension:durchfuehrungsabsicht |
S | 0..1 | Coding | Intention URL: https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht Binding: MII VS Prozedur Durchführungsabsicht [SNOMED CT] (required) | ||||
| 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 | Additional content defined by implementations 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 | Additional content defined by implementations 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_Onko_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 Slice: Unordered, Open by value:url | ||||
| 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 |
SΣC | 0..* | Reference(CarePlan) | A request for this procedure Constraints: ref-1 | ||||
| partOf |
SΣC | 0..* | Reference(MII PR Onkologie Operation) | Part of referenced event Constraints: ref-1 | ||||
| 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 | Art der Operation Binding: BIH LM Senologie Operation (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 | |||||
| Slices for coding |
Σ | 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 code Binding: MII_VS_Onko_Mamma_Operation_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 | |||||
| extension:Seitenlokalisation |
S | 0..1 | Coding | Optional Extensions Element URL: http://fhir.de/StructureDefinition/seitenlokalisation Binding: KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) | ||||
| 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_Onko_Mamma_Operation_SCT (required) Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version |
Σ | 0..1 | string | Version of the system - if relevant | ||||
| code |
SΣ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display |
Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject |
SΣC | 1..1 | Reference(Patient) | Who the procedure was performed on Constraints: ref-1 | ||||
| encounter |
SΣC | 0..1 | Reference(Encounter) | Encounter Constraints: ref-1 | ||||
| Slices for performed[x] |
SΣ | 1..1 | dateTime | Performed date Slice: Unordered, Open by type:$this | ||||
| performed[x]:performedDateTime |
SΣ | 0..1 | dateTime | When the procedure was performed | ||||
| performed[x]:performedPeriod |
Σ | 0..1 | Period | Performed period | ||||
| recorder |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Who recorded the procedure Constraints: ref-1 | ||||
| asserter |
ΣC | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure Constraints: ref-1 | ||||
| Slices for performer |
SΣ | 0..* | BackboneElement | The people who performed the procedure Slice: Unordered, Open by pattern:function | ||||
| performer:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| 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 |
ΣC | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| performer:erstoperateur |
SΣ | 0..1 | 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 Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 1..1 | CodeableConcept | Erstoperateur (G08) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 304292004 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgeon (occupation) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| performer:zweitoperateur |
SΣ | 0..1 | 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 Slice: Unordered, Open by value:url | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| function |
Σ | 1..1 | CodeableConcept | Zweitoperateur (G09) Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 309388001 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Surgical assistant (occupation) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| actor |
SΣC | 1..1 | Reference(Practitioner | PractitionerRole) | The reference to the practitioner Constraints: ref-1 | ||||
| onBehalfOf |
C | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for Constraints: ref-1 | ||||
| location |
ΣC | 0..1 | Reference(Location) | Where the procedure happened Constraints: ref-1 | ||||
| reasonCode |
Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference |
SΣC | 0..* | Reference(MII PR Onkologie Diagnose Primärtumor) | Bezogene Diagnose Constraints: ref-1 | ||||
| bodySite |
SΣ | 0..* | CodeableConcept | Body site Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| 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: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 | Outcome der Operation, v.a. bei Revision Binding: MII VS Onkologie Beurteilung des lokalen Residualstatus (required): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
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 |
C | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure Constraints: ref-1 | ||||
| Slices for complication |
S | 0..* | CodeableConcept | Komplikation (oBDS / ICD-10) 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): Codes describing complications that resulted from a 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 |
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: ICD10GM ValueSet (required): Codes describing complications that resulted from a 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 |
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 |
C | 0..* | Reference(Condition) | A condition that is a result of the procedure Constraints: ref-1 | ||||
| Slices for followUp |
S | 0..* | CodeableConcept | Instructions for follow up Slice: Unordered, Open by pattern:$this Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | ||||
| followUp:drainage |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 122462000 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Drainage procedure | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:verband |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 182531007 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Dressing of wound | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:antibiotika |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 281789004 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Antibiotic therapy (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:mobilisation |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 183040004 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Mobilization (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| followUp:laborkontrolle |
0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. 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 | |||||
| coding |
SΣ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 15220000 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory test (procedure) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| note |
S | 0..* | Annotation | Note | ||||
| 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 Slice: Unordered, Open by value:url | |||||
| 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 |
C | 1..1 | Reference(Device) | Device that was changed Constraints: ref-1 | ||||
| usedReference |
C | 0..* | Reference(Device | Medication | Substance) | Items used during procedure Constraints: ref-1 | ||||
| Slices for usedCode |
S | 0..* | CodeableConcept | Verwendete Codes Slice: Unordered, Open by pattern:$this Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | ||||
| usedCode:IntraoperativesImaging |
S | 0..* | CodeableConcept | Intraoperatives Präparateröntgen/Sonografie Binding: FHIRDeviceTypes (example): Codes describing items used during a 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 |
Σ | 0..* | Coding | Code defined by a terminology system Binding: MII_VS_Onko_Mamma_Intraoperatives_Imaging_Praeparat (extensible) | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| usedCode:PraeoperativeMarkierung |
S | 0..* | CodeableConcept | Präoperative Markierung Binding: FHIRDeviceTypes (example): Codes describing items used during a 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 |
Σ | 0..* | Coding | Code defined by a terminology system Binding: MII_VS_Onko_Mamma_Praeoperative_Markierung_Modalitaet (extensible) | ||||
| text |
Σ | 0..1 | string | Plain text representation of the concept | ||||
| 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:Intention.value[x] | Base | required | MII VS Onkologie Operation Intention | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.extension:Urgency.value[x] | Base | required | MII_VS_Onko_Operation_Urgency | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| 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 | required | BIH LM Senologie Operation | 📦0.9.0 | This IG |
| Procedure.category.coding:sct | Base | preferred | MII VS Prozedur OPS Kategorien [SNOMED CT] | 📦2026.0.0 | MII IG Core Dataset Base v2026.0 |
| Procedure.code | Base | example | Procedure Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.code.coding:ops | Base | required | MII_VS_Onko_Mamma_Operation_OPS | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.code.coding:sct | Base | required | MII_VS_Onko_Mamma_Operation_SCT | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.performer.function | Base | example | Procedure Performer Role Codes | 📦4.0.1 | FHIR Std. |
| Procedure.performer:erstoperateur.function | Base | example | Procedure Performer Role Codes | 📦4.0.1 | FHIR Std. |
| Procedure.performer:zweitoperateur.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 | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication | Base | example | Condition/Problem/Diagnosis Codes | 📦4.0.1 | FHIR Std. |
| Procedure.complication:compl_obds | Base | required | MII VS Onkologie Operation Komplikationen | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.complication:compl_icd10 | Base | required | ICD10GM ValueSet | 📦1.5.4 | de.basisprofil.r4 v1.5 |
| Procedure.followUp | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:drainage | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:verband | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:antibiotika | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:mobilisation | Base | example | Procedure Follow up Codes (SNOMED CT) | 📦4.0.1 | FHIR Std. |
| Procedure.followUp:laborkontrolle | 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. |
| Procedure.usedCode:IntraoperativesImaging | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:IntraoperativesImaging.coding | Base | extensible | MII_VS_Onko_Mamma_Intraoperatives_Imaging_Praeparat | 📦2026.0.3 | MII IG Onkologie v2026.0 |
| Procedure.usedCode:PraeoperativeMarkierung | Base | example | FHIR Device Types | 📦4.0.1 | FHIR Std. |
| Procedure.usedCode:PraeoperativeMarkierung.coding | Base | extensible | MII_VS_Onko_Mamma_Praeoperative_Markierung_Modalitaet | 📦2026.0.3 | MII IG Onkologie v2026.0 |
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()
|
| ref-1 | error | Procedure.basedOn, Procedure.partOf, Procedure.subject, Procedure.encounter, Procedure.recorder, Procedure.asserter, Procedure.performer.actor, Procedure.performer.onBehalfOf, Procedure.performer:erstoperateur.actor, Procedure.performer:erstoperateur.onBehalfOf, Procedure.performer:zweitoperateur.actor, Procedure.performer:zweitoperateur.onBehalfOf, Procedure.location, Procedure.reasonReference, Procedure.report, Procedure.complicationDetail, Procedure.focalDevice.manipulated, Procedure.usedReference | SHALL have a contained resource if a local reference is provided |
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
|
| 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()
|
This structure is derived from MII_PR_Onko_Mamma_Operation
Summary
Mandatory: 0 element(2 nested mandatory elements)
Must-Support: 11 elements
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of Procedure.performer
- The element 1 is sliced based on the value of Procedure.followUp
Other representations of profile: CSV, Excel, Schematron