German Oncological Data Standard (GOLD)
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Resource Profile: Radiological read procedure for clinical TNM

Official URL: https://www.vision-zero-oncology.de/fhir/StructureDefinition/radiological-tnm-read-procedure Version: 0.1.0
Draft as of 2023-12-13 Computable Name: TNM_Radiological_Read_Procedure

Copyright/Legal: CC-BY-SA-4.0

This radiological procedure profile describes the radiological reading process following TNM criteria. It derives from the Radiological_Read_Procedure and needs to define which entity and in which version the read was performed.

Usage:

Formal Views of Profile Content

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

This structure is derived from Radiological_Read_Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*Radiological_Read_ProcedureAn action that is being or was performed on a patient
... code 1..1CodeableConceptIdentification of the procedure
Binding: Valueset for TNM Radiological Read Procedures (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.coderequiredVS_TNM_Radiological_Read_Procedures
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*Radiological_Read_ProcedureAn action that is being or was performed on a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 103693007
..... display1..1stringRepresentation defined by the system
Fixed Value: Diagnostic procedure
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... code Σ1..1CodeableConceptIdentification of the procedure
Binding: Valueset for TNM Radiological Read Procedures (required)
... subject Σ1..1Reference(Patient)Who the procedure was performed on
... report S1..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.statusrequiredEventStatus
Procedure.categoryexampleFixed Value: SNOMED CT code 103693007("Diagnostic procedure")
Procedure.coderequiredVS_TNM_Radiological_Read_Procedures

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*Radiological_Read_ProcedureAn action that is being or was performed on a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ1..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.


Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 103693007
..... display1..1stringRepresentation defined by the system
Fixed Value: Diagnostic procedure
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... code Σ1..1CodeableConceptIdentification of the procedure
Binding: Valueset for TNM Radiological Read Procedures (required)
... subject Σ1..1Reference(Patient)Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report S1..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..*Reference(Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleFixed Value: SNOMED CT code 103693007("Diagnostic procedure")
Procedure.coderequiredVS_TNM_Radiological_Read_Procedures
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Radiological_Read_Procedure

Summary

Mandatory: 1 element

Differential View

This structure is derived from Radiological_Read_Procedure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*Radiological_Read_ProcedureAn action that is being or was performed on a patient
... code 1..1CodeableConceptIdentification of the procedure
Binding: Valueset for TNM Radiological Read Procedures (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Procedure.coderequiredVS_TNM_Radiological_Read_Procedures

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*Radiological_Read_ProcedureAn action that is being or was performed on a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 103693007
..... display1..1stringRepresentation defined by the system
Fixed Value: Diagnostic procedure
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... code Σ1..1CodeableConceptIdentification of the procedure
Binding: Valueset for TNM Radiological Read Procedures (required)
... subject Σ1..1Reference(Patient)Who the procedure was performed on
... report S1..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.statusrequiredEventStatus
Procedure.categoryexampleFixed Value: SNOMED CT code 103693007("Diagnostic procedure")
Procedure.coderequiredVS_TNM_Radiological_Read_Procedures

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Procedure 0..*Radiological_Read_ProcedureAn action that is being or was performed on a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierExternal Identifiers for this procedure
... instantiatesCanonical Σ0..*canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire)Instantiates FHIR protocol or definition
... instantiatesUri Σ0..*uriInstantiates external protocol or definition
... basedOn Σ0..*Reference(CarePlan | ServiceRequest)A request for this procedure
... partOf Σ0..*Reference(Procedure | Observation | MedicationAdministration)Part of referenced event
... status ?!Σ1..1codepreparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown
Binding: EventStatus (required): A code specifying the state of the procedure.

... statusReason Σ0..1CodeableConceptReason for current status
Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed.

... category Σ1..1CodeableConceptClassification of the procedure
Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes.


Fixed Value: As shown
.... id0..0stringUnique id for inter-element referencing
.... extension0..0ExtensionAdditional content defined by implementations
.... coding1..1CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..0stringUnique id for inter-element referencing
..... extension0..0ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..0stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 103693007
..... display1..1stringRepresentation defined by the system
Fixed Value: Diagnostic procedure
..... userSelected0..0booleanIf this coding was chosen directly by the user
.... text0..0stringPlain text representation of the concept
... code Σ1..1CodeableConceptIdentification of the procedure
Binding: Valueset for TNM Radiological Read Procedures (required)
... subject Σ1..1Reference(Patient)Who the procedure was performed on
... encounter Σ0..1Reference(Encounter)Encounter created as part of
... performed[x] Σ0..1When the procedure was performed
.... performedDateTimedateTime
.... performedPeriodPeriod
.... performedStringstring
.... performedAgeAge
.... performedRangeRange
... recorder Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Who recorded the procedure
... asserter Σ0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole)Person who asserts this procedure
... performer Σ0..*BackboneElementThe people who performed the procedure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... function Σ0..1CodeableConceptType of performance
Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure.

.... actor Σ1..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device)The reference to the practitioner
.... onBehalfOf 0..1Reference(Organization)Organization the device or practitioner was acting for
... location Σ0..1Reference(Location)Where the procedure happened
... reasonCode Σ0..*CodeableConceptCoded reason procedure performed
Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required.


... reasonReference Σ0..*Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference)The justification that the procedure was performed
... bodySite Σ0..*CodeableConceptTarget body sites
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.


... outcome Σ0..1CodeableConceptThe result of procedure
Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise.

... report S1..*Reference(DiagnosticReport | DocumentReference | Composition)Any report resulting from the procedure
... complication 0..*CodeableConceptComplication following the procedure
Binding: Condition/Problem/DiagnosisCodes (example): Codes describing complications that resulted from a procedure.


... complicationDetail 0..*Reference(Condition)A condition that is a result of the procedure
... followUp 0..*CodeableConceptInstructions for follow up
Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures.


... note 0..*AnnotationAdditional information about the procedure
... focalDevice 0..*BackboneElementManipulated, implanted, or removed device
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... action 0..1CodeableConceptKind of change to device
Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure.

.... manipulated 1..1Reference(Device)Device that was changed
... usedReference 0..*Reference(Device | Medication | Substance)Items used during procedure
... usedCode 0..*CodeableConceptCoded items used during the procedure
Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure.



doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Procedure.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Procedure.statusrequiredEventStatus
Procedure.statusReasonexampleProcedureNotPerformedReason(SNOMED-CT)
Procedure.categoryexampleFixed Value: SNOMED CT code 103693007("Diagnostic procedure")
Procedure.coderequiredVS_TNM_Radiological_Read_Procedures
Procedure.performer.functionexampleProcedurePerformerRoleCodes
Procedure.reasonCodeexampleProcedureReasonCodes
Procedure.bodySiteexampleSNOMEDCTBodyStructures
Procedure.outcomeexampleProcedureOutcomeCodes(SNOMEDCT)
Procedure.complicationexampleCondition/Problem/DiagnosisCodes
Procedure.followUpexampleProcedureFollowUpCodes(SNOMEDCT)
Procedure.focalDevice.actionpreferredProcedureDeviceActionCodes
Procedure.usedCodeexampleFHIRDeviceTypes

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorProcedureIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorProcedureIf 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-4errorProcedureIf 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-5errorProcedureIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceProcedureA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from Radiological_Read_Procedure

Summary

Mandatory: 1 element

 

Other representations of profile: CSV, Excel, Schematron