Canonical URL: http://fhir.de/StructureDefinition/condition-de-basis/0.2
| Condition | 0..* | Condition | Short description Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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| extension | 0..* | Extension | Short description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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| Diagnosesicherheit | 0..1 | Extension(CodeableConcept) | Short description Diagnosesicherheit lt. ICD-10-GM Alternate namesextensions, user content DefinitionDiese Extension kann zur Angabe der Diagnosesicherung in ICD-10-GM-Codierung verwendet werden. Die Angabe der äquivalenten Werte für clinicalStatus und verificationStatus ist in diesem Fall dennoch zwingend. Die Äquivalente gelten wie folgt: "A" (ausgeschlossen) => clinicalStatus = leer, verificationStatus="refuted" "G" (gesicherte Diagnose) => clinicalStatus = "active", verificationStatus="confirmed" "V" (Verdacht auf / zum Ausschluss von) => clinicalStatus = "active", verificationStatus="provisional" "Z" (Zustand nach) => clinicalStatus = "resolved", verificationStatus="confirmed" There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2 Constraints
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| identifier | Σ | 0..* | Identifier | Short description External Ids for this condition DefinitionThis records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). Need to allow connection to a wider workflow.
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| clinicalStatus | Σ ?! | 0..1 | codeBinding | Short description active | recurrence | inactive | remission | resolved DefinitionThe clinical status of the condition. This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern.
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| verificationStatus | Σ ?! | 0..1 | codeBinding | Short description provisional | differential | confirmed | refuted | entered-in-error | unknown DefinitionThe verification status to support the clinical status of the condition. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid. condition-ver-status (required) Constraints
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| category | 0..* | CodeableConcept | Short description problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
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| severity | 0..1 | CodeableConceptBinding | Short description Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. condition-severity (preferred) Constraints
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| code | Σ | 0..1 | CodeableConcept | Short description Identification of the condition, problem or diagnosis Alternate namestype DefinitionIdentification of the condition, problem or diagnosis. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| coding | Σ | 0..* | Coding | Short description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
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| ICD-10-GM | Σ | 0..* | CodingBinding | Short description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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| extension | 0..* | Extension | Short description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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| Haupt-Code_Kreuz-Code | 0..1 | Extension(CodeableConcept) | Short description Der Haupt- bzw. Kreuz-Code Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz/0.2 Constraints
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| Stern-Code | 0..* | Extension(CodeableConcept) | Short description Stern-Code Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/icd-10-gm-stern/0.2 Constraints
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| Ausrufezeichen-Code | 0..* | Extension(CodeableConcept) | Short description Ausrufezeichen-Code Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen/0.2 Constraints
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| system | Σ | 1..1 | uriFixed Value | Short description ICD-10-GM DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://fhir.de/CodeSystem/dimdi/icd-10-gm
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| version | Σ | 1..1 | string | Short description Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") DefinitionBie Verwendung von ICD-10-GM ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von ICD-10-GM ein neues Codesystem darstellt. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | Short description Der ICD-10-Code DefinitionDer ICD-10-Code, einschließlich verbundener Codes (Kreuz-Stern-Notation, Ausrufezeichen-Notation. Vgl. hierzu auch die Dokumentation zu iCD in der FHIR-Spezifikation. Die Einzelbestandteile von postkoordinierten Codes (einzelne ICD-10-GM-Codes) können über die im Profil definierten Extensions einzeln dokumentiert werden. Die Angabe des postkoordinierten Codes ist in diesem Fall dennoch zwingend. Seitenlokalisaion und Diagnosesichrheit sollten, soweit vorhanden, in den Elementen bodySite bzw. clinicalStatus/verificationStatus codiert werden. Für die Diagnosesicherkeit kann zusätzlich auch die entsprechende Extension verwendet werden. Die Angabe von clinicalStatus und/oder verificationStatus ist jedoch in diesen Fällen zwingend, da es sich hierbei um modifizierende Angaben (modyfiers) handelt. Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
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| display | Σ | 0..1 | string | Short description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
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| userSelected | Σ | 0..1 | boolean | Short description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | Short description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| bodySite | Σ | 0..* | CodeableConcept | Short description Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both.
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| extension | 0..* | Extension | Short description Additional Content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Constraints
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| Lokalisations-Referenz | 0..1 | Extension | Short description Lokalisations-Referenz Alternate namesextensions, user content DefinitionReferenz auf eine Lokalisation. Zur detaillierteren Darstellung von Lokalisationen mittels der BodySite-Ressource Hinweis: ab FHIR R4 wird diese Ressource als BodyStructure bezeichnet, dementsprechend ändert sich dann auch der Name der Extension! There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://hl7.org/fhir/StructureDefinition/body-site-instance Constraints
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| url | 1..1 | uriFixed Value | Short description identifies the meaning of the extension DefinitionSource of the definition for the extension code - a logical name or a URL. The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.
http://hl7.org/fhir/StructureDefinition/body-site-instance
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| valueReference | 0..1 | Reference(BodySite) | Short description Value of extension DefinitionValue of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). A stream of bytes, base64 encoded
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| coding | Σ | 0..* | Coding | Short description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by system(Value) Constraints
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| ICD-10-GM-Seitenlokalisation | Σ | 0..1 | CodingBinding | Short description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. http://fhir.de/ValueSet/kbv/s_icd_seitenlokalisation (required) Constraints
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| system | Σ | 1..1 | uriFixed Value | Short description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.
http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation
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| version | Σ | 0..1 | string | Short description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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| code | Σ | 1..1 | code | Short description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings may not exceed 1MB in size
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| display | Σ | 0..1 | string | Short description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings may not exceed 1MB in size
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| userSelected | Σ | 0..1 | boolean | Short description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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| text | Σ | 0..1 | string | Short description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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| subject | Σ | 1..1 | Reference(Group | Patient, deutsches Basisprofil (Version 0.2)) | Short description Who has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with. Group is typically used for veterinary or public health use cases. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Group | Patient, deutsches Basisprofil (Version 0.2)) Constraints
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| context | Σ | 0..1 | Reference(Encounter | EpisodeOfCare) | Short description Encounter or episode when condition first asserted Alternate namesencounter DefinitionEncounter during which the condition was first asserted. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known". Reference(Encounter | EpisodeOfCare) Constraints
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| onset[x] | Σ | 0..1 | Short description Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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| onsetDateTime | dateTime | Data Type | ||
| onsetAge | Age | Data Type | ||
| onsetPeriod | Period | Data Type | ||
| onsetRange | Range | Data Type | ||
| onsetString | string | Data Type | ||
| abatement[x] | 0..1 | Short description If/when in resolution/remission DefinitionThe date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.
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| abatementDateTime | dateTime | Data Type | ||
| abatementAge | Age | Data Type | ||
| abatementBoolean | boolean | Data Type | ||
| abatementPeriod | Period | Data Type | ||
| abatementRange | Range | Data Type | ||
| abatementString | string | Data Type | ||
| assertedDate | Σ | 0..1 | dateTime | Short description Date record was believed accurate DefinitionThe date on which the existance of the Condition was first asserted or acknowledged. The assertedDate represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified. The date of the last record modification can be retrieved from the resource metadata.
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| asserter | Σ | 0..1 | Reference(RelatedPerson | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2)) | Short description Person who asserts this condition DefinitionIndividual who is making the condition statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(RelatedPerson | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2)) Constraints
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| stage | 0..1 | BackboneElement | Short description Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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| summary | 0..1 | CodeableConcept | Short description Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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| assessment | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Short description Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ClinicalImpression | DiagnosticReport | Observation) Constraints
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| evidence | 0..* | BackboneElement | Short description Supporting evidence DefinitionSupporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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| code | Σ | 0..* | CodeableConcept | Short description Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. manifestation-or-symptom (example) Constraints
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| detail | Σ | 0..* | Reference(Resource) | Short description Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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| note | 0..* | Annotation | Short description Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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Einfache Diagnose:
<Condition> <meta> <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" /> </meta> <text> <status value="generated" /> --- We have skipped the narrative for rendering purposes --- </text> <code> <coding> <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" /> <version value="2017" /> <code value="Q90.0" /> <display value="Trisomie 21, meiotische Non-disjunction" /> </coding> <text value="Trisomie 21, meiotische Non-disjunction" /> </code> <subject> <reference value="Patient/12345" /> </subject> </Condition>
Diagnose mit Seitenlokalisation:
<Condition> <meta> <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" /> </meta> <text> <status value="generated" /> --- We have skipped the narrative for rendering purposes --- </text> <code> <coding> <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" /> <version value="2017" /> <code value="S51.9" /> <display value="Schnittwunde am Unterarm" /> </coding> <text value="Schnittwunde am Unterarm" /> </code> <bodySite> <coding> <system value="http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation" /> <code value="L" /> <display value="links" /> </coding> <text value="links" /> </bodySite> <subject> <reference value="Patient/12345" /> </subject> </Condition>
Diagnose mit Angabe der Diagnosesicherheit:
<Condition> <meta> <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" /> </meta> <text> <status value="generated" /> --- We have skipped the narrative for rendering purposes --- </text> <extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2"> <valueCodeableConcept> <coding> <system value="http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit" /> <code value="V" /> </coding> </valueCodeableConcept> </extension> <clinicalStatus value="active" /> <verificationStatus value="provisional" /> <code> <coding> <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" /> <version value="2017" /> <code value="I21.9" /> <display value="Herzinfarkt" /> </coding> <text value="Herzinfarkt" /> </code> <subject> <reference value="Patient/12345" /> </subject> </Condition>
Diagnose mit Angabe der Seitenlokalisation und der Diagnosesicherheit:
<Condition> <meta> <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" /> </meta> <text> <status value="generated" /> --- We have skipped the narrative for rendering purposes --- </text> <extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2"> <valueCodeableConcept> <coding> <system value="http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit" /> <code value="G" /> </coding> </valueCodeableConcept> </extension> <clinicalStatus value="active" /> <verificationStatus value="confirmed" /> <code> <coding> <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" /> <version value="2017" /> <code value="S51.9" /> <display value="Schnittwunde am Unterarm" /> </coding> <text value="Schnittwunde am Unterarm" /> </code> <bodySite> <coding> <system value="http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation" /> <code value="L" /> <display value="links" /> </coding> <text value="links" /> </bodySite> <subject> <reference value="Patient/12345" /> </subject> </Condition>
Einfache Diagnose:
{ "resourceType":"Condition", "meta":{ "profile": [ "http://fhir.de/StructureDefinition/condition-de-basis/0.2" ] }, "text":{ "status":"generated", --- We have skipped the narrative for rendering purposes --- }, "code":{ "coding": [ { "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version":"2017", "code":"Q90.0", "display":"Trisomie 21, meiotische Non-disjunction" } ], "text":"Trisomie 21, meiotische Non-disjunction" }, "subject":{ "reference":"Patient/12345" } }
Diagnose mit Seitenlokalisation:
{ "resourceType":"Condition", "meta":{ "profile": [ "http://fhir.de/StructureDefinition/condition-de-basis/0.2" ] }, "text":{ "status":"generated", --- We have skipped the narrative for rendering purposes --- }, "code":{ "coding": [ { "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version":"2017", "code":"S51.9", "display":"Schnittwunde am Unterarm" } ], "text":"Schnittwunde am Unterarm" }, "bodySite": [ { "coding": [ { "system":"http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation", "code":"L", "display":"links" } ], "text":"links" } ], "subject":{ "reference":"Patient/12345" } }
Diagnose mit Angabe der Diagnosesicherheit:
{ "resourceType":"Condition", "meta":{ "profile": [ "http://fhir.de/StructureDefinition/condition-de-basis/0.2" ] }, "text":{ "status":"generated", --- We have skipped the narrative for rendering purposes --- }, "extension": [ { "url":"http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2", "valueCodeableConcept":{ "coding": [ { "system":"http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit", "code":"V" } ] } } ], "clinicalStatus":"active", "verificationStatus":"provisional", "code":{ "coding": [ { "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version":"2017", "code":"I21.9", "display":"Herzinfarkt" } ], "text":"Herzinfarkt" }, "subject":{ "reference":"Patient/12345" } }
Diagnose mit Angabe der Seitenlokalisation und der Diagnosesicherheit:
{ "resourceType":"Condition", "meta":{ "profile": [ "http://fhir.de/StructureDefinition/condition-de-basis/0.2" ] }, "text":{ "status":"generated", --- We have skipped the narrative for rendering purposes --- }, "extension": [ { "url":"http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2", "valueCodeableConcept":{ "coding": [ { "system":"http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit", "code":"G" } ] } } ], "clinicalStatus":"active", "verificationStatus":"confirmed", "code":{ "coding": [ { "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version":"2017", "code":"S51.9", "display":"Schnittwunde am Unterarm" } ], "text":"Schnittwunde am Unterarm" }, "bodySite": [ { "coding": [ { "system":"http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation", "code":"L", "display":"links" } ], "text":"links" } ], "subject":{ "reference":"Patient/12345" } }
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