Grundsätzlich gilt zu beachten, dass Attribute wie "Aufnahme- oder Entlass-Diagnose", sowie Rangfolgen von Diagnosen stets im Kontext eines Behandlungsfalles zu sehen sind. Sie werden daher als Eigenschaft des Encounters modelliert.
<diagnosis> <condition> <reference value="Condition/example"/> </condition> <use> <coding> <system value="http://terminology.hl7.org/CodeSystem/diagnosis-role"/> <code value="DD"/> <display value="Entlassdiagnose"/> </coding> </use> <rank value="1"/> </diagnosis>
<diagnosis> <condition> <reference value="Condition/example"/> </condition> <use> <coding> <system value="http://hl7.org/fhir/diagnosis-role"/> <code value="CC"/> <display value="Hauptdiagnose"/> </coding> </use> <rank value="1"/> </diagnosis>
| Condition | 0..* | Condition | Element IdCondition 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.
| |
| identifier | Σ | 0..* | Identifier | Element IdCondition.identifier External Ids for this condition DefinitionBusiness identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
|
| clinicalStatus | Σ ?! | 0..1 | CodeableConceptBinding | Element IdCondition.clinicalStatus active | recurrence | relapse | inactive | remission | resolved DefinitionThe clinical status of the condition. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
|
| verificationStatus | Σ ?! | 0..1 | CodeableConceptBinding | Element IdCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error 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. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. condition-ver-status (required) Constraints
|
| category | 0..* | CodeableConceptBinding | Element IdCondition.category 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. condition-category (extensible) Constraints
| |
| severity | 0..1 | CodeableConceptBinding | Element IdCondition.severity 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
| |
| code | Σ | 1..1 | CodeableConcept | Element IdCondition.code 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.
|
| coding | Σ | 1..* | Coding | Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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
|
| ICD-10-GM | Σ | 1..1 | Coding-Profil für ICD-10-GMBinding | Element IdCondition.code.coding:ICD-10-GM A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
|
| extension | 0..* | Extension | Element IdCondition.code.coding:ICD-10-GM.extension 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. 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 can 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
| |
| HauptKreuzCode | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:ICD-10-GM.extension:HauptKreuzCode Optional Extensions Element 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz Constraints
| |
| SternCode | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:ICD-10-GM.extension:SternCode Optional Extensions Element 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-stern Constraints
| |
| AusrufezeichenCode | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:ICD-10-GM.extension:AusrufezeichenCode Optional Extensions Element 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen Constraints
| |
| Diagnosesicherheit | 0..1 | Extension(Coding) | Element IdCondition.code.coding:ICD-10-GM.extension:Diagnosesicherheit Optional Extensions Element 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-diagnosesicherheit Constraints
| |
| system | Σ | 1..1 | uriFixed Value | Element IdCondition.code.coding:ICD-10-GM.system Canonische ValueSet URL für 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 reference to some definition that establishes the system clearly and unambiguously.
http://fhir.de/CodeSystem/dimdi/icd-10-gm
|
| version | Σ | 1..1 | string | Element IdCondition.code.coding:ICD-10-GM.version 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.
|
| code | Σ | 1..1 | code | Element IdCondition.code.coding:ICD-10-GM.code Der (ggf. postkoordinierte) ICD-10-Code DefinitionDer ICD 10 Code ist vollständig anzugeben, ggf. in postkoordinierter Form Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
Postkoordinierter Kreuz-Stern-Code A12.3+ B45.6* Einfacher ICD-Code F17.4 Mappings
|
| display | Σ | 0..1 | string | Element IdCondition.code.coding:ICD-10-GM.display 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 SHALL NOT exceed 1MB in size
|
| userSelected | Σ | 0..1 | boolean | Element IdCondition.code.coding:ICD-10-GM.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. 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.
|
| text | Σ | 0..1 | string | Element IdCondition.code.text 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.
|
| bodySite | Σ | 0..* | CodeableConcept | Element IdCondition.bodySite 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 bodySite. May be a summary code, or a reference to a very precise definition of the location, or both.
|
| coding | Σ | 0..* | Coding | Element IdCondition.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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
|
| ICD-10-GM-Seitenlokalisation | Σ | 0..1 | CodingBinding | Element IdCondition.bodySite.coding:ICD-10-GM-Seitenlokalisation Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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/CodeSystem/kbv/s_icd_seitenlokalisation (required) Constraints
|
| system | Σ | 1..1 | uri | Element IdCondition.bodySite.coding:ICD-10-GM-Seitenlokalisation.system 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 reference to some definition that establishes the system clearly and unambiguously.
|
| version | Σ | 0..1 | string | Element IdCondition.bodySite.coding:ICD-10-GM-Seitenlokalisation.version 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.
|
| code | Σ | 1..1 | code | Element IdCondition.bodySite.coding:ICD-10-GM-Seitenlokalisation.code 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 SHALL NOT exceed 1MB in size
|
| display | Σ | 0..1 | string | Element IdCondition.bodySite.coding:ICD-10-GM-Seitenlokalisation.display 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 SHALL NOT exceed 1MB in size
|
| userSelected | Σ | 0..1 | boolean | Element IdCondition.bodySite.coding:ICD-10-GM-Seitenlokalisation.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. 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.
|
| text | Σ | 0..1 | string | Element IdCondition.bodySite.text 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.
|
| subject | Σ | 1..1 | Reference(Patient| Group) | Element IdCondition.subject 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.
|
| encounter | Σ | 0..1 | Reference(Encounter) | Element IdCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. 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".
|
| onset[x] | Σ | 0..1 | Element IdCondition.onset[x] 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.
| |
| onsetDateTime | dateTime | Data Type | ||
| onsetAge | Age | Data Type | ||
| onsetPeriod | Period | Data Type | ||
| onsetRange | Range | Data Type | ||
| onsetString | string | Data Type | ||
| abatement[x] | 0..1 | Element IdCondition.abatement[x] 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.
| ||
| abatementDateTime | dateTime | Data Type | ||
| abatementAge | Age | Data Type | ||
| abatementPeriod | Period | Data Type | ||
| abatementRange | Range | Data Type | ||
| abatementString | string | Data Type | ||
| recordedDate | Σ | 0..1 | dateTime | Element IdCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
|
| recorder | Σ | 0..1 | Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) | Element IdCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. 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(Practitioner| PractitionerRole| Patient| RelatedPerson) Constraints
|
| asserter | Σ | 0..1 | Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) | Element IdCondition.asserter 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(Practitioner| PractitionerRole| Patient| RelatedPerson) Constraints
|
| stage | 0..* | BackboneElement | Element IdCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
| |
| summary | 0..1 | CodeableConcept | Element IdCondition.stage.summary 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.
| |
| assessment | 0..* | Reference(ClinicalImpression| DiagnosticReport| Observation) | Element IdCondition.stage.assessment 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
| |
| type | 0..1 | CodeableConcept | Element IdCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. 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. condition-stage-type (example) Constraints
| |
| evidence | 0..* | BackboneElement | Element IdCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
| |
| code | Σ | 0..* | CodeableConcept | Element IdCondition.evidence.code 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
|
| detail | Σ | 0..* | Reference(Resource) | Element IdCondition.evidence.detail 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.
|
| note | 0..* | Annotation | Element IdCondition.note 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).
|
